Month Old Twin Boy Died After Medical Staff Missed Bleeding On Brain

Family Wants Lessons To Be Learnt As NHS Report and Coroner Criticise Care Given To New Born Baby


Dave Grimshaw, Press Officer | 0114 274 4397

The devastated family of a twin boy who died just over a month after his birth after medical staff failed to spot and treat bleeding and fluid on his brain despite him being rushed to hospital several times say they hope lessons are learned to prevent others suffering in future.

Micah Smith and his twin brother were born on 13 June 2013 at East Surrey Hospital by emergency caesarean. They were discharged after a few days but Micah had problems feeding and a midwife recommended a tongue tie separation procedure which was carried out at a local clinic on 25 June.

Over the following days, Micah became unwell showing signs of irritability and abnormal neurological signs that were not acted upon and over the next few weeks he was in and out of Epsom General Hospital while he was wrongly treated for reflux and an infection despite signs and symptoms pointing to a neurological cause and increasing maternal concern.  

Staff had missed that Micah was suffering from a brain haemorrhage and subsequent hydrocephalus (fluid on the brain) and on 13 July he collapsed and needed resuscitation. He was transferred to St George’s Hospital in Tooting where scans showed he had suffered irreversible brain damage and intensive care was withdrawn. He died on 15 July 2013.

His family has instructed specialist medical negligence lawyers at Irwin Mitchell to investigate the incident as they believe his death was preventable. An internal investigation by the Epsom and St.Helier University Hospitals NHS Trust identified 16 concerns about the care Micah received at Epsom General Hospital and made several recommendations including the need for new policies to be written and further training for paediatric staff.

At the Inquest on 22 and 23 September in Woking, the Coroner, Dr Karen Henderson, gave a narrative conclusion yesterday saying that Micah died from hydrocephalus secondary to raised intracranial pressure from a naturally occurring intraventricular haemorrhage which there was a delay in diagnosing and consequently, effective treatment could not have been instituted. 

At both of the admissions to hospital, the Coroner found that the staff failed to exclude other causes of Micah’s symptoms. Dr Henderson found that Micah’s death was preventable. Had the staff considered neurological causes, they would have diagnosed the haemorrhage and the hydrocephalus and avoided the acute collapse and ultimately Micah’s death. In particular, a simple examination of the head circumference of a baby and repeat measurements would have identified the progressive hydrocephalus. The Trust confirmed during the Inquest that the paediatric admission sheet now has the head circumference as standard for babies under the age of one year.

The Trust’s own internal investigation prepared in September 2015 found that there was poor record keeping and that further tests should have been carried out on several occasions which may have led the correct diagnosis well before Micah’s acute deterioration shortly before his collapse. 

One of the care concerns relates to the failure of the Emergency Department to complete an Early Warning System score. Irwin Mitchell is also instructed by the family of another child who died 9 months after Micah, also at Epsom General Hospital and one of the concerns in that case was also the failure to complete an Early Warning System score. The assessments by staff in that case were also criticised. 

The Coroner was critical of Trust for its poor communication with the family after Micah’s death and delay in conducting its internal investigation. The Coroner expressed that she would like the Trust to have the opportunity to write a full explanation as to the circumstances.

Expert Opinion
“The family is obviously devastated by Micah’s death. They are pleased that the Coroner has investigated what happened but they still have many concerns about the care Micah received in his tragically short life.

“His family are disappointed that the Trust’s internal investigation report has taken over two years to produce. They believe such reports should be produced as soon as possible after an incident such as this and steps taken to address the care concerns immediately to prevent similar incidents."
Auriana Griffiths, Partner

Micah’s mother Lisa Smith, aged 32, from Epsom, Surrey, said: “We are devastated beyond words at losing Micah in this way. His brothers will never get to grow up with Micah and it saddens us to know that if the mistakes had not been made in his care he would still be with us today.

“It should have been clear something was seriously wrong as we had been in and out of hospital a few times but they just didn’t spot what was wrong because they didn’t do the right checks. They didn’t listen to my concerns. I knew something was terribly wrong but they kept reassuring me and telling me it was just reflux. 

“Nothing can ever bring Micah back but we just hope that now the NHS will learn from this and make changes to stop this happening to others. I would hate for another family to go through what we have had to over the past few years.”

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