Mojeri Adeleye was born seriously premature at the Jessop Wing after his mum was transferred from a hospital in Grimsby.<\/p>\n
Author: Roland Sebestyen, Local Democracy Reporting ServicePublished 48 minutes ago<\/p>\n
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.<\/p>\n
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 \u2013 despite the mother pointing out the error in medical notes. <\/p>\n
In a Prevention of Future Deaths report, the assistant coroner for South Yorkshire (West District) found there was a \u201clack of regard\u201d for the mother\u2019s knowledge of her pregnancy, as well as a \u201clack of discussion\u201d with the parents about potential measures that could be taken in the event of premature labour before the 22-week threshold. <\/p>\n
The coroner noted that Mojeri\u2019s mother had been supported during her pregnancy in Grimsby but due to concerns and complications \u2013 for example the premature rupture of membranes \u2013 she was transferred to Jessops Wing in Sheffield. <\/p>\n
The coroner said: \u201cUnfortunately, Mojeri\u2019s mother\u2019s referral notes in respect of her expected due date were not correct. <\/p>\n
\u201cDespite this being brought to the attention of staff multiple times, the staff at the Jessops Wing refused to accept that Mojeri\u2019s mother was providing them with the correct information.\u201d <\/p>\n
According to the coroner, Abigail Combes, Mojeri\u2019s 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. <\/p>\n
However, the information held by the hospital was \u201cincorrect\u201d as he was just over the 22 weeks gestation mark. <\/p>\n
Ms Combes said: \u201cI was told in evidence that the single biggest feature in Mojeri\u2019s 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. <\/p>\n
\u201cI 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.\u201d <\/p>\n
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. <\/p>\n
She sent this report to Sheffield Teaching Hospitals NHS Foundation Trust stating \u201cin my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action\u201d. <\/p>\n
The inquest concluded that Mojeri Adeleye\u2019s cause of death was extreme prematurity and pre-labour premature rupture of membranes. <\/p>\n
Kirsten Major, chief executive of the Sheffield Teaching Hospitals NHS Foundation Trust, responded to the report, saying: \u201cI wanted to express how saddened I was by Mojeri\u2019s death and how sorry I am for the distress and upset which this has no doubt caused his parents. <\/p>\n
\u201cI 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.\u201d <\/p>\n
She added she acknowledged due regard was not given to the information provided to them by Mojeri\u2019s mother and as a result the trust had revised its policies \u201cto 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.\u201d <\/p>\n
The chief executive added she believed in Mojeri\u2019s case the staff displayed a degree of confirmation bias and because of this, they have included \u201chuman factors\u201d in their mandatory training. <\/p>\n
To further support this, the service introduced a consultant of the week stating January 1 in 2023 \u201cto provide an enhanced level\u201d of support to the maternity unit every week. <\/p>\n
The chief executive also accepted that there were \u201cmissed opportunities\u201d to discuss possible measures both following rupture of membranes at 17 weeks and following Mojeri\u2019s mum\u2019s admission in spontaneous labour. <\/p>\n
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. <\/p>\n
There is also a specific training regarding the management of extreme prematurity in the Bereavement Study Day \u201cto support staff to advocate effectively for women in this situation and provide appropriate comfort care.\u201d<\/p>\n