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‘Guardian Angel’ Died After Hospital Laboratory Failed To Tell Doctors About Baby’s Abnormally High Insulin Levels

Mum Issues Warning To Parents About Condition Which Claimed Son’s Life

23.01.2018

Dave Grimshaw, Press Officer | 0114 274 4397

A mum from East London is warning parents to be aware of the signs of low blood sugar levels in babies after the condition claimed her 23-day-old son’s life.

Sabreena Smith has spoken for the first time about her loss after an inquest concluded that her son, who had abnormally high insulin levels, would probably have survived had there not been ‘failings’ in diagnosing his condition.

Following Caliel Smith Kwami’s death, Sabreena, of Canning Town, instructed expert medical negligence lawyers at Irwin Mitchell to investigate the care her son received at the hands of Barts Health NHS Trust, which runs the Royal London Hospital.

Caliel had spent the first few days of his life in intensive care because of low blood sugar levels. However, he was discharged from the Royal London Hospital before ‘key’ insulin test results were known.

A broken machine which should have analysed Caliel’s insulin levels caused a delay in doctors knowing the results. Medical staff should have chased the results, and if they had received them, they could have referred Caliel for specialist care to treat his condition, an inquest found.

Community midwives were also not told about Caliel’s discharge from hospital. Subsequently they ‘missed an opportunity’ to chase up his test results.  

Caliel suffered a cardiac arrest on the day his mum registered his birth. He died later that day from neonatal hyperinsulinemic hypoglycaemia - a condition and effects of low blood glucose caused by excessive insulin.

Paying tribute to her son, Sabreena, 26, said: “Before he was born we spent a long time choosing Caliel’s name which means ‘my guardian angel’. Once it was decided I was so intent on the name but at the time I didn’t know why. It is now fitting as he is my guardian angel.”

“Caliel was taken from us far too soon but the three weeks I had with him were the best of my life; my life has now been ripped apart since his death.”

Caliel was born in a good condition at Barkantine Birth Centre, part of the Royal London Hospital, on 25 July, 2016. Following his birth midwifery staff supported Sabreena, giving advice how to feed her son.

However, the following day Caliel was admitted to Royal London Hospital after he was found to be ‘floppy and cold’ during a routine midwife assessment.

On 2 August Caliel was discharged from hospital as his condition and his blood sugar levels had improved.

On 17 August Caliel turned blue while out with his mum. Sabreena ran with her baby to a nearby GP surgery for help and a doctor started CPR. Caliel was taken to Newham General Hospital but died a couple of hours later despite attempts to resuscitate him.

Following Caliel’s death a Comprehensive Investigation Report was conducted by Barts Health NHS Trust. It recommended that all neonatal test results were followed up before babies were discharged from hospital.

An inquest into his death criticised procedures in place at Royal London Hospital.

Recording a narrative verdict, Coroner, Miss Nadia Persaud concluded that:

  • Doctors should have chased the laboratory for the results after not hearing anything for a few days
  • The laboratory team should have alerted doctors that the analyser machine was broken
  • The hospital failed to tell community health workers Caliel had been discharged so they could book a health check appointment
  • Had Caliel’s results been known prior to his discharge or shortly after a health visitor appointment a specialist could have carried out further investigations into his condition.

The Coroner has written to Barts Health raising concerns over a lack of ‘chasing results and accountability’ as well as recommending bedside ketone tests are introduced.

Sabreena added: “Caliel was a character from the moment he arrived home. Everyone would comment how strong, alert and happy he was. We used to laugh how greedy he was.

“Following Caliel’s death I did some research which suggested that early warning signs of low blood sugar in babies include irritability, deep snoring, turning a bluish colour or going limp and that if a mother notices any of those signs then the advice is take to baby to A&E.

“I was never told any of this when being discharged from the hospital. When the question was raised of how to avoid Caliel’s blood sugars dropping again I was told as long as he is feeding regularly every two to three hours everything should be fine.

“Caliel would cry a lot during the night and was very hard to settle becoming irritable especially at night, being a first time mum I just put this down to him being a newborn baby.

“My son was failed by those who were supposed to be caring for him. If the correct procedures were followed and I had been told the correct information regarding how to spot a drop in his blood sugar levels I feel that my son would still be alive today.

“My only hope now is that other parents are aware of the signs of low blood sugar levels so they can take immediate action.”

Expert Opinion
Sabreena and her family have been left devastated by the death of Caliel and are still struggling to come to terms with the circumstances of his death.

“While the last three days have been distressing for Sabreena as she listened to the evidence presented at the inquest we thank the Coroner for the thorough investigation. It is now imperative that the hospital trust learns lessons from Caliel’s death so other families don’t have to suffer the anguish that Sabreena and her family have.

“While nothing can bring Caliel back we will continue to work with Sabreena and her family to help support them through this distressing time.”
Jasicca Nava, Solicitor

Read more about Irwin Mitchell's expertise in handling medical negligence cases.