Inquest hears consultant 'forgot' to move catheter before baby death

The inquest is being held at the Medico-Legal Centre in Sheffield

A consultant has told an inquest she has no explanation why she forgot to move an incorrectly positioned feeding line shortly before a baby died.

Cassian Curry died two days after being born at Sheffield Teaching Hospitals' Jessop Wing on 5 April 2021.

Dr Elizabeth Pilling said she intended to move a catheter, which was close to the baby's heart, but never did.

"I've been round and round - why did I forget?" she told the inquest in Sheffield.

Cassian was born prematurely at 28 weeks during the Easter bank holiday weekend, weighing 1lb 10oz (750g).

He was given an umbilical venous catheter by two junior doctors, but it was in a "sub-optimal" position by his heart, Dr Pilling said.

She had intended to have it repositioned within 24 hours but first waited because of the dangers of repeatedly handling a baby as premature as Cassian.

"I can't explain why I didn't do it in that situation, apart from the acuity of the unit," she said

The inquest heard how Cassian died from a cardiac tamponade, which is when fluid builds up in the space around the heart, eventually preventing it from pumping.

Dr Pilling told the coroner she was shocked at Cassian's sudden deterioration because he had been doing well for his size and prematurity.

'Very busy' unit

Cassian Curry died at Sheffield Teaching Hospitals' Jessop Wing maternity unit in April 2021

The consultant said she was starting work on her fifth consecutive 12-hour day shift on Easter Sunday when she was reminded by her registrar about the position of the line on an X-ray.

She said she did not think it was an urgent matter but had intended that it should be changed at some time during the day but "it went out of my head".

Cassian's parents, Karolina and James Curry, have expressed concerns that understaffing over the Easter bank holiday contributed to their son's death.

Dr Pilling said the unit was properly staffed according to national guidelines and there were no absences.

However, she told the coroner it was very busy - with large numbers of admissions and discharges plus complex cases.

She said this was exacerbated by many of the staff on duty being at the junior end of their scales, meaning she was regularly being asked for her support.

The consultant added she was aware of junior members of staff having submitted internal incident reports with concerns about staffing issues.

Coroner Abigail Combes has told the inquest she will consider whether negligence contributed to Cassian's death when she concludes the hearing on Friday.