Hospital Admits Series Of Care Failings Led To Tragic Baby Death

Heartbroken Mum says ‘More Must be Done’ To Protect Patients And Launches Campaign For Change In Hospital Procedures

14.11.2012

The heartbroken mother of a one-year-old girl who died at Birmingham Children’s Hospital after staff repeatedly ignored signs that her condition was deteriorating says there needs to be a change in culture in the NHS after the trust admitted responsibility for the failings that led to her death.

Hayley Fullerton had just celebrated her first birthday when she suffered heart failure after undergoing corrective surgery for a heart condition she had been born with. Her death occurred on 11th November 2009 – twelve days after being transferred from the children’s hospital’s intensive care unit to a general ward where her condition was allowed to slowly deteriorate until it was too late to save her.

Following an inquest, which today (Wednesday 14th November) returned a narrative verdict, specialist medical lawyers from Irwin Mitchell who have represented the family in their three-year battle for answers, confirmed the hospital trust has now fully admitted that a catalogue of ‘serious failings’ were responsible for Hayley’s tragic and avoidable death.

During the inquest, which was heard in May but adjourned for the verdict, mum Paula Stevenson, told HM Coroner for Birmingham and Solihull Aidan Cotter, that over a period of seven days nurses ignored her pleas to help Hayley and she was made to feel like a ‘paranoid parent’ who was wasting their time.

It heard how Paula became so desperate that she even tried to motivate a nurse to take proper care of her baby daughter by offering her a £100 gift voucher.

The hospital trust subsequently carried out internal investigations and found that an alarming catalogue of errors by staff on ward 11 of Birmingham Children’s Hospital had led to Hayley’s tragic death.

These serious errors put to the trust included:

  • A failure over a period of seven days to identify Hayley’s worsening condition
  • A failure to seek a review with other clinicians or refer her back to the Paediatric Intensive Care Unit (PICU)
  • Systemic failings within the trust and a ‘hierarchical culture’ amongst staff on ward 11 which, combined with a misunderstanding of when a patient should be referred, prevented staff from sending Hayley back to PICU for urgent treatment.
  • A gross failure to provide treatment – specifically to help Hayley breathe - given her worsening condition and obvious signs of respiratory distress

Mandy Luckman, a medical negligence expert and Partner at Irwin Mitchell’s Birmingham office, said: “Given the trust has now admitted full liability, there needs to be an urgent review to determine whether the system failings put to the trust during the inquest, and as accepted in the trust’s own internal investigation report, have now been remedied.

“Hayley’s family – and indeed any parent whose child requires critical care at Birmingham Children’s Hospital - need reassurance that all clinical and nursing staff now clearly understand the criteria for a young patient needing urgent referral to PICU. We also hope that the trust has taken steps to remove the old hierarchical culture at the hospital which, in effect, prevented medical staff from doing their job.

“Although nothing can turn back the clock for Paula and her family, who continue to suffer the most unimaginable heartache, they are determined that Hayley’s death will not be completely in vain and will hopefully create a catalyst for change in the NHS.”

Hayley Fullerton was born in Belfast on October 6th 2008 with a congenital heart abnormality that meant blood could not get from her heart to her lungs. Her parents, Bobby Fullerton and Paula Stevenson, were told that their daughter’s condition would require corrective surgery when she was around 12 months old.

As the heart surgeon who had been looking after Hayley in Belfast was due to retire, Birmingham Children’s Hospital was recommended as an alternative because of its reputation for clinical excellence. Paula, who were now living in Queensland, Australia, took the decision to fly Hayley back to the UK for treatment, having to leave behind her husband to continue to run his business.

Surgery to repair Hayley’s heart, which took place on 14th October 2009, was successful and after spending a few days in intensive care (PICU) she was moved to a general ward.

It was there that she suffered breathing complications which were not properly treated for seven days. On the morning of 11 November, Hayley suffered a cardiac arrest after her lungs collapsed. A crash team was called but it was too late to save her.

Speaking after today’s verdict and the trust’s full admission of liability, mum Paula Stevenson, 40, said: “Our entire family has been completely devastated by what happened and to this day we continue to grieve for Hayley.

“Our beautiful little girl would still be with us if the nurses who were supposed to be caring for her had come to her aid sooner. I still cannot understand how trained medics could ignore the fact that she was slowly deteriorating before their eyes. “They had seven days to spot that something was seriously wrong but all those precious opportunities were missed.

“My parents and I never left Hayley’s bedside during the entire time she was in hospital and it was obvious to us, despite our lack of medical training, that she was a very sick little girl who needed help.

“I did all I could to try to get the nurses to help her but my appeals just fell on deaf ears. At one point, after I had complained that Hayley wasn’t getting the treatment she needed, she was moved to an isolation room, with staff claiming she might have swine flu.

“This diagnosis was later found to be completely wrong but it meant we were moved even further from the nurses’ station and couldn’t attract their attention easily. It was as though Hayley had been placed in isolation as a punishment for me daring to speak up on her behalf.”

Paula continued: “Regardless of the Trust’s admission that the ‘hierarchy’ hampered staff from referring Hayley back to PICU, it only needed one nurse to show an ounce of compassion and common sense. It is to their shame that not one of them saw fit to ask for an urgent second opinion.

“Hayley was neglected in the worst possible way. She had successfully overcome the heart surgery, only to suffer complications which resulted in her suffering a slow, distressing death. My daughter was a little fighter but towards the end she battled so hard to breathe that her lungs gradually stopped working and it became too much for her frail body to cope with.”

Paula Stevenson has now launched a campaign in an attempt to empower other parents and change the NHS culture so that anyone who voices concerns about their child’s care in hospital is given the right to request an urgent second opinion.

The campaign website, www.heal-trust.org featuring Paula’s younger 12 month old daughter, Casey, is calling on the NHS to put in place measures which will ensure that medical staff are willing to listen to parents’ concerns and take action, in a bid to help save patients’ lives.

Paula also paid tribute to Dr Casey who works at the Clark Clinic at the Royal Belfast Hospital for Sick Children. She said: “It is testament to Dr Casey’s utmost dedication and expertise that Hayley’s heart condition was diagnosed when I was only 22 weeks pregnant.

“I had flown from Australia to Ireland to show off my ‘baby bump’ but subsequently found out the problem Hayley had. If it wasn’t for Dr Casey diagnosing Hayley’s heart condition she would have remained undiagnosed and it is unlikely she would have survived past birth.

“I am so thankful to Dr Casey and his team at the Clark Clinic as he allowed me to have the privilege of knowing and loving Hayley for that year. I have even called my younger daughter ‘Casey’ after him as he will always remain an important part of our lives.”

If you have lost a loved one due to fatal negligence, we may be able to help you claim compensation. See our Medical Negligence Guide for more information.