Baby boy died just hours after being born when ‘doctors failed to carry out basic life-saving tests'
A BABY died just hours after birth when hospital staff missed signs of a collapsed lung, a coroner has ruled.
Little Benjamin Finch Arnold was born prematurely at St James' Hospital in Leeds in 2022.
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Soon after birth, he developed serious breathing problems, which is not uncommon among babies born early.
But crucial, basic life-saving tests were not carried out in time, an inquest into his death has found.
It heard Benjamin could have survived if doctors had acted sooner to diagnose and treat a pneumothorax - a condition where air leaks into the chest and causes the lung to collapse.
Leeds Teaching Hospitals NHS Trust (LTHT), which runs the hospital, said it was "extremely sorry that Benjamin died whilst in our care".
Last month, coroner Oliver Longstaff ruled Benjamin's death was avoidable.
Around three hours after he was born, Benjamin underwent a procedure to help his underdeveloped lungs breathe, during which his lungs collapsed.
Efforts to resuscitate him were unsuccessful and he was pronounced dead less than eight hours after he was born.
Mr Longstaff said staff "missed opportunity to consider the possibility" of a pneumothorax as the cause of his breathing problems early on in the process.
This is because procedure policy "did not mandate a chest X-ray", which he said would probably have revealed it, the BBC reports.
A further opportunity was also missed when the medic performing the procedure did not discuss it with the neonatal consultant involved, the coroner added.
One sip of my porn star martini and I was in utter agony – my lung collapsed and I was gasping for breath
The consultant would likely have asked if a pneumothorax had been ruled out as a cause of Benjamin's condition, the conclusion read.
Mr Longstaff said: "No thought was given to the pneumothorax being a potential, and potentially reversible, cause of the collapse.
"If they had been treated he would have, on the balance of probabilities, survived."
Mr Longstaff has since issued a Prevention of Future Deaths report, aiming to prevent similar tragedies.
He sent this report to the Health Secretary, Leeds Teaching Hospitals NHS Trust, and other relevant bodies.
He said maternity services in Leeds are dangerously split between two hospitals, with St James' lacking proper medical and paediatric support.
Plans to bring all services under one roof have been delayed until at least 2030.
There was also confusion over how the St James' unit is classified, with staff describing it as operating at a higher level than officially recognised.
What is a collapsed lung?
A pneumothorax - also known as a collapsed lung - happens when air has leaked out from the lung in to the chest cavity and chest wall.
This causes the lung to collapse down and peel away from the inside of the chest.
When someone who doesn't have any known lung problems develops a pneumothorax, this is called a primary pneumothorax.
Usually the air has leaked from a blister on the surface of the lung which has been present from birth.
A lung can also collapse as a result of conditions like chronic obstructive pulmonary disease or emphysema, as well as injuries to the chest wall that cause damage to lung surfaces.
The condition most commonly occurs in smokers.
The most common symptoms are sudden shortness of breath and chest pain, which may be sharp and worse with coughing and breathing.
You may also experience a dry cough.
If air has leaked out into the muscles and skin in your chest wall, you may notice a swelling and a 'bubble wrap' sensation if you press on your chest.
Occasionally, if the leak of air has been very large, you may feel faint or light headed.
A pneumothorax is usually diagnosed through an X-ray.
Source: NHS
The coroner warned that NHS guidelines for a breathing procedure called LISA are inconsistent, and questioned whether national rules for treating cardiac arrest in newborns are good enough.
Finally, he said changes made by the Trust after Benjamin's death need to be properly explained. All organisations involved must respond by July 28.
'This cannot wait any longer'
Earlier this year, Benjamin's parents described the care their son received as 'unacceptable'.
"We are devastated by Benjamin's death," they said in a statement sent to the BBC.
"The standard of care he received was unacceptable.
"We urge Leeds Teaching Hospitals Trust to take the prevention of future deaths report seriously.
"We ask the government to urgently provide the funding for the new hospital building in Leeds.
"This would allow all maternity and neonatal care to be provided from a single site and improve patient safety.
"This cannot wait any longer."
Dr Magnus Harrison, Chief Medical Officer at Leeds Teaching Hospitals NHS Trust, said: 'I am extremely sorry that Benjamin died whilst in our care and I cannot imagine how difficult the last three years have been for his family.
'We have already made important changes, including ensuring a consultant neonatologist is available on each hospital site and involved earlier in complex procedures.
'While these changes do not undo the loss of Benjamin, we will continue to review and improve our services to provide the best possible care for our babies and their families.
'We appreciate the coroner's thorough investigation and are preparing a response to the recommendations to provide the assurances he is seeking.'
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