After being born 13 weeks early by cesarean section, the two pound two ounce baby girl was suffering from respiratory problems and transferred to a specialist unit at another hospital.
Only two days old the baby was placed on a ventilator when the endotracheal tube that was attached to the ventilator became dislodged. In the period of time before the hospital staff had noticed that the baby’s tube had become displaced, she had already suffered significant oxygen loss. It then took another several minutes because the Doctor treating her had no special training in incubation, it took two tubes and four attempts before he was able to get the tube into the trachea to assist her with her breathing.
At 49 days old the baby died in her mothers arms. The pathologist did a report which showed that she had died from a hypoxic brain injury which stemmed from the displacement of her ventilator tube. The baby, while in the care at the hospital had suffered over-ventilation causing complications as well.
The pathologist stated that the aftermath of the brain damage was ‘quite extensive and widespread’ and was consistent with the damage from the tube displacement.
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