Mojeri Adeleye was born seriously premature at the Jessop Wing after his mum was transferred from a hospital in Grimsby.
Author: Roland Sebestyen, Local Democracy Reporting ServicePublished 8 hours ago
A coroner has raised serious concerns after a premature baby, Mojeri Adeleye, died in a Sheffield hospital when staff refused to believe a crucial date was wrong.
A life-saving procedure was not carried about because staff failed to acknowledge that he had reached the gestational age at which such care should have been considered – despite the mother pointing out the error in medical notes.
In a Prevention of Future Deaths report, the assistant coroner for South Yorkshire (West District) found there was a “lack of regard” for the mother’s knowledge of her pregnancy, as well as a “lack of discussion” with the parents about potential measures that could be taken in the event of premature labour before the 22-week threshold.
The coroner noted that Mojeri’s mother had been supported during her pregnancy in Grimsby but due to concerns and complications – for example the premature rupture of membranes – she was transferred to Jessops Wing in Sheffield.
The coroner said: “Unfortunately, Mojeri’s mother’s referral notes in respect of her expected due date were not correct.
“Despite this being brought to the attention of staff multiple times, the staff at the Jessops Wing refused to accept that Mojeri’s mother was providing them with the correct information.”
According to the coroner, Abigail Combes, Mojeri’s mother had gone into labour but due to a policy, guided by national practice, no life saving support had been offered to the baby because he was under 22 weeks gestation.
However, the information held by the hospital was “incorrect” as he was just over the 22 weeks gestation mark.
Ms Combes said: “I was told in evidence that the single biggest feature in Mojeri’s death was the much earlier premature rupture of membranes at 17 weeks gestation and that even if the correct gestational age had been known there would not have been different treatment offered.
“I was also told in evidence that conversations about whether exceptional measures will be taken to support premature babies take place in the 22nd week of pregnancy rather than in the 21st.”
Concluding her report, the coroner raised concerns about the procedure and noted that there is a risk that future deaths could occur unless action is taken.
She sent this report to Sheffield Teaching Hospitals NHS Foundation Trust stating “in my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action”.
The inquest concluded that Mojeri Adeleye’s cause of death was extreme prematurity and pre-labour premature rupture of membranes.
Kirsten Major, chief executive of the Sheffield Teaching Hospitals NHS Foundation Trust, responded to the report, saying: “I wanted to express how saddened I was by Mojeri’s death and how sorry I am for the distress and upset which this has no doubt caused his parents.
“I would like to assure you that we have learnt from this case and taken actions to ensure that as far as is possible, nothing similar happens again.”
She added she acknowledged due regard was not given to the information provided to them by Mojeri’s mother and as a result the trust had revised its policies “to ensure that where there is any conflicting information with regard to due dates we would check the findings of a validated dating scan and communicate with the mother to ensure that the information is correct.”
The chief executive added she believed in Mojeri’s case the staff displayed a degree of confirmation bias and because of this, they have included “human factors” in their mandatory training.
To further support this, the service introduced a consultant of the week stating January 1 in 2023 “to provide an enhanced level” of support to the maternity unit every week.
The chief executive also accepted that there were “missed opportunities” to discuss possible measures both following rupture of membranes at 17 weeks and following Mojeri’s mum’s admission in spontaneous labour.
So the trust is working with the Yorkshire and Humber Joint Maternity Clinical Forum and the Local Maternity and Neonatal System to formalise and standardise pathways of care which includes the level of counselling families receive and the measures that are taken.
There is also a specific training regarding the management of extreme prematurity in the Bereavement Study Day “to support staff to advocate effectively for women in this situation and provide appropriate comfort care.”