Inquest Returns Narrative Verdict Following Death Of Four-Week Old Baby

Heart Defect missed

15.07.2009

A family is calling for lessons to be learned after a Sandwell coroner today returned a narrative verdict following the death of a four week old baby from the Black Country after a heart defect was missed.

Baby Kieran Cannings was born on 7th March 2007 at Sandwell Hospital. During her pregnancy, Kieran's mother, Katie Hodgetts, had undergone several specialist scans at Birmingham Women’s Hospital because her partner, Damian Cannings, had been diagnosed with a heart defect when he was a baby.

Damian's heart defect was first detected when he turned blue at just six weeks of age. He required an operation to rectify the heart defect (total pulmonary venous drainage), followed by frequent check-ups which, as he grew older, took place every five years.

When Kieran was born, the inquest heard no specific checks were made of his heart, despite his Father's heart condition and the specialist scans performed during the pregnancy.

Baby Kieran was discharged from the hospital on 9th March and neither of his parents recalls any particular checks being made. Photographs taken at the time also show that his hands were blue.

The community midwife made home visits and Kieran's parents recall informing her that when he fed he had a blue/purple line around his mouth but this was explained as trapped wind. They also remember telling the health visitor about the purple line and this was recorded in the notes of 30th March. She scheduled to visit again within six weeks.

According to Damian and Katie, Kieran did not cry much during the first weeks, but by the end of March this changed. The morning of 6th April Katie fed Kieran at 09:00 and again at 11:00. Just before 12:00pm he started to gasp and then stopped breathing. Katie telephoned 999 while Damian performed resuscitation. Paramedics took Kieran to hospital but, despite efforts to resuscitate him, he died at 12:31pm.

The post mortem confirmed that Kieran had died from anomalous pulmonary venous connection (APVC), symptoms of which usually present during the first hours after birth and occasionally are delayed by up to a week. Signs include blue lips and a heart murmur.

Commenting on today's verdict, Delia Cannings, Kieran’s grandmother, commented: "We warned the doctors and midwives about Damian's heart condition and Katie was scanned several times during her pregnancy. I simply do not understand why Kieran was not examined more closely and more attention wasn't paid when his Mum and Dad said they were worried about his blue lips.

"If Kieran had been scanned and a heart defect noticed, he could have had surgery, like my son, and could well have grown to be a parent himself. However, my lovely grandson has died and we are asking ourselves what more could we have done to make the medical experts pay more attention? Damian and Katie now have another son, Jayden, who was born in June this year and he could have enjoyed having an older brother."

Caroline Stokes, a solicitor with the Birmingham office of law firm, Irwin Mitchell, is acting for the Cannings who are planning to take legal action against the Trust. She said: "Kieran's family are disappointed by today's verdict.

"They are understandably very distressed by the circumstances of his death and are frustrated that the special care and monitoring which Katie received during her pregnancy, was not followed up once Kieran was born.

"Details of the family's history of heart problems were not transferred onto Kieran's medical notes and therefore he received no special screening before being discharged from hospital.

"At the inquest, a medical expert made the important point that nowadays this condition is not usually fatal, provided it is diagnosed and treated.

"All the symptoms that Kieran had a congenital heart abnormality were present but crucially this information was not shared between medical professionals and as a result no-one was able to 'join the dots' and come to the obvious conclusion that Kieran needed urgent treatment.

"We are keen to seek assurances from the Trust that lessons have been learned to prevent a similar tragedy from occurring in the future."