A coroner has slammed a hospital for “failing to provide basic medical care” to a two-month-old baby girl who tragically died.

The inquest resumed into the death of Louella Sheridan after previously taking place in June and March this year.

Louella, of Daffodil Road, Farnworth, tragically died on April 24 last year at the Royal Bolton Hospital after her oxygen levels declined.

Bolton Coroners Court previously heard that all alarms were possibly switched off due to no alarms sounding when Louella died.

Before Louella was born a test revealed that she had a chromosome abnormality, and after a doctor had listened to her heart, and discovered that her heart blood vessel was too narrow.

The Bolton News: She was then transferred to Alder Hey Children’s Hospital.

Following surgery on February 25 to close Louella’s heart, her lungs collapsed, and she was transferred to the high dependency unit, where she was fed on a nasogastric tube, and her parents were shown how to use this.

Louella was then discharged on March 15 with follow up appointments discussed.

Louella was taken to Royal Bolton Hospital in April after a visit by a community nurse, when the baby "didn't look well" and oxygen saturation levels were down.

During yesterday’s inquest (Wednesday December 20) Detective Inspector Dave Sinclair said that an investigation launched during the inquest to look at witnesses statements found “insufficient evidence” to show that a crime had been committed at a criminal standard, but recognised there were “issues” when it came to hospital policy and actions taken.

Det Insp Sinclair looked at whether the course of justice was perverted, and whether there was any perjury in relation to witness statements previously given, and gross negligence manslaughter.

He said: “I think it’s reasonable to conclude that it’s more likely than not that all the alarms were turned off.

“There seems to have been no effective quarantine of the monitor or module [equipment] or the required system."

Det Insp Sinclair added: “From the evidence I have seen, there are clearly issues around continuity, and any potential evidence of it being lost.

The Bolton News: “The product we got at the end doesn’t have any real value.

“I didn’t find any intentional acts or deliberate acts, but there was evidence of policy issues, and evidence of the actions taken.

“There is insufficient evidence to show an offence committed at a criminal standard.”

Following the inquest in June, matron of the paediatrician ward, Jayne Simpson said that a number of actions have since been rolled out, including regular audits of equipment, and a checklist to say equipment involved in a death has been isolated.

Face-to-face training is also being implemented to staff on how to use the devices correctly, with signs, and information telling staff not to ‘switch any alarms off’.

She said: “We have put a number of things in place, and we have taken learning from this case.

“If there were any shortcomings, we would look at ways to improve that from the audit.

“We will continue to learn if we need to make changes to processes.

“Most the actions have been completed, and some are ongoing.”

Ms Simpson confirmed that it was not possible to disable the option to turn the alarms off all together, and that it was possible that this could still happen, but the volume is not able to go beyond 0, meaning it’s “always audible”.

She said: “You can not switch off that function on the machine, but staff have been informed not to do so.

The Bolton News: “We have done this to make sure everyone is following the clear instructions.

“If someone comes in overnight, we would check the audit the next day and takes place on a daily basis.”

Ms Simpson said that there are clear signs not to switch off the alarms in the wards now, as well as standards and training that highlight this.

A business case is  being put forward in February 2024 to purchase a system which retains the patient data and details.

Concerns were previously raised over whether correct Covid policies were followed after evidence given said that the door was “slightly ajar”, given that Louella tested positive for Covid.

The medical cause of death given by pathologist Dr Melanie Newbold was Covid-19 with pulmonary hypertension, associated with congenial ventricular septal defect, with myocardial hypertrophy, with myocardial fibrosis.

Nurse Hannah Malone had also incorrectly recorded the Paediatric Early Warning Score, and Coroner Prof John Pollard said that she “demonstrated a serious lack of “understanding”, which should have been recorded as a three instead of a two, which would have led to a medical review.

The isolating of equipment was described as a “totally chaotic situation on and around the ward”, and  Prof Pollard said he had “no credible or believable evidence”.

He said: “I heard the evidence from the matron Andrew Butler.

“The evidence of Butler was unbelievably confused, inappropriate, uncaring and his manner totally unhelpful.

“Had he not left the trust I would have been compelled to make representation on his manner in a coroners’ court.

“The investigation by the hospital trust did not really help me at all, but I can see efforts have been made to rectify certain issues.

“I find that the care by Alder Hey Children’s Hospital was satisfactory.

“The care by the community nurses just about reached the level the level of satisfactory.

“The care by Royal Bolton Hospital fell well below expected by a large hospital of that type.”

Prof Pollard went on to say that there was “clearly a failure to provide basic medical care”.

He continued: “Had the alarms been switched on they would have alerted medical staff and Louella’s life might have been extended.

“It is reasonable to conclude that if the alarms had not been silenced, they would have alerted staff and they would have worked on her for some time and her life would have been extended for a short time.

“I find the switching off of the alarms was a gross misconduct.

“I thank all the advocates, witnesses, and everybody who has helped me, and most of all the family.

“The way you have conducted yourselves in what must have been a very sad and distressing process, and I thank you.”

Louella died as a result of natural causes contributed to by neglect, and Prof Pollard is now considering whether a report to prevent future deaths is needed.

Louella’s mother Casey Quigley said: “Louella deserved a chance to live but as a family we feel that the actions taken by the hospital’s staff took that chance away from her.

“Not a day has gone by, in the 20 months since her death, that we haven’t re-lived that night and wished our daughter was here with us.

“Louella was our precious baby girl and is missed very much by her brothers and sisters, who will also be affected by her loss for the rest of their lives.

“The only small comfort we have is that the inquest and our legal case might stop the same thing from happening to other vulnerable babies.

“That’s our only hope.”

Rachael Heyes, a specialist medical negligence solicitor at law firm JMW, who is handling Casey and Granville’s legal case, said: “The inquest process has been harrowing for Casey and Granville and only made worse by the handling of it by the hospital, which caused the hearing to be delayed by more than a year.

“We welcome the coroner’s verdict and hope his comments serve as a warning to staff.

“No patient should have monitoring equipment turned off, particularly not a vulnerable baby. “The conclusion of the inquest brings some closure for Casey and Granville and although they will never fully recover from this tragedy, is an important milestone for them.”

Tyrone Roberts, Chief Nurse at Bolton NHS Foundation Trust said: “I want to extend my sincere condolences to Casey, Granville and all of Louella’s family as they continue to come to terms with their tragic loss.

“We fully accept the outcome of the inquest and are incredibly sorry that on this occasion our systems and processes that should have cared for Louella, fell below our standards.

“We’ve made changes to improve this but acknowledge there is still work to do, based on the coroner’s recommendations.

“I know saying we are sorry will never be enough.

"We are committed to making sure we learn everything we can from what happened and will make any changes necessary to prevent such a tragedy from happening again.”

If you have a story and something you would like to highlight in the community, please email me at jasmine.jackson@newsquest.co.uk or DM me on Twitter @JournoJasmine.