Bolton: Day two of inquest continues into death of baby

The second day of the inquest of little Louella Sheridan, of Daffodil Road, Farnworth, who tragically died on April 24 last year at the Royal Bolton Hospital after her oxygen levels declined took place on Tuesday.

Oxygen saturation is a measure of how much haemoglobin is currently bound to oxygen compared to how much haemoglobin remains unbound.

Bolton Coroner's Court heard that the oxygen saturation alarm was "turned off" by ward manager and sister nurse Kirsten Norris during her night shift on April 23, 2022.

She said: “Movement was causing an inaccurate reading of the oxygen saturation.

“You tend to get a wiggle and babies can move about, which can be a problem you get with getting accurate readings.

“In hindsight I should have switched it back on and shouldn’t have switched it off.

“I assessed the risk and at the time my priority was to settle Louella with the CPAP machine for her potential bronchiolitis and observe her in the room.

“An example is when we had an autistic boy whose movement was causing inaccuracies.

“I observed Louella and could see she was moving around and was well perfused.”

Bolton Coroner's Court (Image: Newsquest)

Questions were raised as to how the two patients in the high dependency unit – with one of them being Louella – were both able to be cared for during a two-hour break given to nurse Rachel Birtwistle.

Coroner, Professor John Pollard, said that if the nurse was in another cubicle with another patient, she “couldn’t know what was happening”.

He said: “What would have happened if you were called to deal with another emergency?”

Ms Norris said: “I would have asked other staff or nurse Birtwistle.

“You can also see the monitor readings because the room was outside a three bedded cubicle and had a window, with the door a jarred and a small night light, and lights in the corridor.

“I deemed it acceptable to give her two hours away from the high dependency unit and I would take over Louella’s care.

“I do that with all staff because I know it can be intense.”

The inquest also heard that hourly checks were carried out, with oxygen levels checked three times an hour, as well as observations of her chart, which showed she was "stable".

Barrister Louise Green, representing Louella’s family, questioned whether all alarms could have been silenced due to the respiratory rate, blood pressure, and heart rate also not sounding, but Ms Norris says that she “knows she didn’t do that” because she would have had to go into each of the settings to silence them.

Issues around whether correct Covid policies were followed, given that Louella tested positive for covid and that there was another other non-Covid patient on the high dependency unit.

Nurse Birtwistle said that she washed her hands when she went in the room, used gel and used PPE, which was thrown in the bin inside Louella’s room.

She said: “The door should have been closed but that is not always achievable if you need to nurse.”

However, it was heard that sometimes PPE was put in the nearest bin at the time.

Day one of the inquest heard that paediatric nurse Hannah Malone – who was on the morning shift on April 24 - had raised an ‘escalation’ at 8am due to her temperature being 38.5, and raised heart rate, and to ask about whether she could have Ibuprofen because she previously had dialysis, which can affect this.

She said: “I wanted to make Dr Thomas Webster aware and I wasn’t overly concerned because I knew the source of infection and cause of temperature.

“She was under three months with a temperature, so I would have escalated it anyway.

“Continue to monitor, was the advice given.”

However, when asked by Miss Green what time Ms Malone went in the room to check on Louella, she “couldn’t recall”, but says that she could see the monitor.

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This was during a 25-minute facetime call that mum Casey Quigley had with the father Granville Sheridan, when they noticed she wasn’t well, and a community nurse and crash team were then called.

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.

The third day of the inquest will continue today, with more evidence expected to be discussed, as well as a conclusion to be formed.