Devastated parents of a “strong” baby girl who was a “fighter” have shared their painful journey in the build-up to an inquest, following her tragic death.

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

The inquest was due to conclude on Wednesday, March 29 as part of a three-day inquest, but it is now expected to continue on June 12 and 13 so more evidence can be obtained about why none of the alarms for heart rate, respiratory rate, and blood pressure sounded.

Louella’s mother Casey Quigley said her death had left the family broken-hearted.

She said: “Louella was a very strong baby from the day she was born.

“She overcame open heart surgery at one week old and she was very special to us.

“She was a fighter, and we are so proud of her.”

The Bolton News:

Upon being admitted to the Royal Bolton, Miss Quigley said that Louella “started to smile”, and that the family “will never forget those moments” they had with her.

She added: “Her brothers and sisters miss her very much.

“We feel as parents if Louella had gone to any other hospital, then she would still be here with us.

“We are heartbroken, and we miss her very much.” 

On day three of the inquest, following evidence that showed Louella’s oxygen saturation alarm was "turned off", coroner Professor John Pollard questioned why this was done when the guidelines stated that “all monitoring alarms must be enabled and audible for nurses”.

Ward manager Jane Simpson – who received a call on April 24 to say that there had been an "unexpected child death"- said: “It’s not a standard I would expect from staff.

“However, there are certain circumstances where we act in the best interests of the child and risk assess and make a clinical decision based on the risk assessment, but it should be justified.”

The inquest heard that Louella was “potentially not admitted or she was discharged as a patient” from the machine following her death, which means that no information has been able to be recovered from the monitor or module which stores the information.

Medical engineer for iFM – outsourced by Royal Bolton Hospital - Karen Stanton said: “Information is stored until the patient is discharged from the monitor.

“The monitor stores patient details and the module can offer that information.

“It’s unclear if that was done.

“We are unable to ascertain any information from that monitor or module.

“You can use the monitor without inputting data.

“You can input that data and that would retain that data.”

The Bolton News:

Paediatric matron Andrew Butler was questioned over whether there was any training involved when it came to using the monitors.

Mr Butler says that staff received face to face training on the high dependency ward (HDU), but that not all staff were able to admit patients other than the admitting nurses.

He said: “There are plans in place to train staff.

“At the time messages went out to say that when patients are admitted to HDU, they should admit them so they can retain the information, and some training took place.

“We emphasise it and make sure staff are comfortable and confident using the monitor.”

Mr Butler said that all staff would be trained by the end of September, but when questioned by Professor John Pollard he said this would be brought forward to the end of April.

He said: “All of the staff won’t be able to admit to the machine because all staff are not HDU trained.

“The HDU staff understand how the machine works, how to attach the equipment , and set parameters and volume but not to admit because that would be with the admitting nurse.”

When barrister Louise Green - representing Louella’s family – asked Mr Butler how a patient would be admitted to the monitor, he said: “You would tap on the bar where it says patient and it would come up with patient, name, surname, and DOB, and potentially the hospital number, and then you click admit."

Prof Pollard said the task of admitting patients by using the monitor was “so simple” and questioned why not all nursing staff are not able to do it.

He said: “It is worrying that such a rudimentary task is not able to be performed by every single one of the nurses on the ward.”

Mr Butler said: “I think if you haven’t had exposure to it you won’t be familiar around the machine.”

The court previously heard that the cubicle that Louella was in had the door “slightly ajar”, and concerns were raised 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 HDU.

Assistant divisional nurse director Faye Chadwick created a serious incident report following the death of Louella and says a number of changes have since been made.

A risk assessment chart pathway has now been created, which allow staff to ‘make decisions’ around the number of nurses treating patients on the HDU.

Faye said: “This flow chart is designed to support decision making as to whether it’s safe for 1-1 care.

“The guidance to support children in HDU says 1-1 care should be considered.”

The Bolton News:

However, Professor Pollard says that for someone in Louella’s condition that the only "proper way" to have nursed her would have been 1-1 care and that the guidance must reflect this.

Leaflets will also now be given out upon first contact with the children’s community nursing team, about how to react and contact community nursing staff, as well as ‘red flags’ to look out for.

Rachael Heyes, a specialist medical negligence solicitor at JMW who is dealing with the family’s legal case, said: “The delay to the conclusion of the inquest was necessary so the coroner could give proper consideration to all the facts but is nonetheless heart-breaking for Louella’s family.

“The coroner will not have taken this decision lightly and we thank him for conducting such a thorough investigation.

“This has been an incredibly distressing and stressful process for my clients to go through and I will continue to support them as they seek answers about what happened to their daughter.”