An inquest into the death of a two-month-old baby girl heard all monitoring alarms were possibly switched off and there were “no signs” to say medical equipment should not be used.

It comes as the inquest of little Louella Sheridan continued on Monday (June 12) after previously taking place over a three-day period in March.

Louella tragically died on April 24 last year at the Royal Bolton Hospital after her oxygen levels declined.

When medical engineering manager Karen Stanton was questioned by coroner, Professor John Pollard, whether it was “possible” or “probable” that all alarms were switched off, she agreed that it was possible.

She added: “With somebody who was unfamiliar with what they were doing even with the best of intentions, it would be very easy, it’s a three-button press.

The Bolton News: baby Louellababy Louella (Image: Public)

“It is possible that the alarms were all switched off because the monitor would have made a noise, unless the parameters were that wide.”

Ms Stanton says this was based on the evidence heard, information seen and experience.

But she also explained that even if all alarms were switched off, there would be a display of the readings, and a warning would come up asking if they wanted to turn all alarms off.

Signs have since been put in place to say that staff “must not switch alarms off”.

This is after it was previously heard that the oxygen saturation alarm was "muted".

Nurse Hannah Malone previously told the inquest that she had raised an "escalation" at 8am on the day she died due to Louella’s temperature being 38.5C, and her raised heart rate.

But she also told the inquest on Tuesday, June 13 that the heart rate alarm had gone off on a couple of occasions.

Barrister Louise Green, representing Louella's family, questioned why this was not previously mentioned “even though Louella died within an hour” and no other alarms sounded at that time.

Miss Malone said: “I didn’t think it was relevant that I heard it at 8am.

“It is not unusual for the alarm to go off.

“When mum said Louella was ill, I don’t recall any other alarm going off.”

Matron of the ward Andrew Butler said that prior to the engineering company, EBME, collecting the equipment on April 25, he told staff “not to admit anyone” and thought the equipment was in the cubicle, having not realised part of it was secured in a high dependency unit (HDU) draw until “later”. 

However, he could not recall if there were any signs.

Prof Pollard added: “You have an unexpected baby death, and you can’t provide any evidence about equipment that could provide all the answers to this family.”

The inquest heard that the equipment was collected on two separate occasions, and there were concerns over whether the right equipment had been taken, and whether the same equipment was used with another patient.

Part of the machine was reportedly discovered in the HDU drawon April 28.

Engineer for EBME, Chris Taylor, who collected the equipment said in a statement that he attended the ward on April 25 and asked a member of staff where the screen was, and there were “no signs it was involved in a serious incident” or that it was quarantined.

He said: “The monitor and module were in there [cubicle] still connected.

“I spoke to a member of staff, and they said the SpO2 (oxygen saturation) wasn’t reading correctly.

“I took the module into the workshop and returned the module to E5 [Children and Young Person's Unit] and reattached it [to the monitor] after I tested it.

“There was nothing reported of it being anything more serious.

The Bolton News:

“If you are taking it from the ward with data and returning it back you would have to delete it for data protection.”

Miss Stanton said that the job came through on their system from the administrator who took notes of the exact details, reported by ward manager Jayne Simpson.

She said: “There is no reason to believe that what was written was not said.

“All my staff are aware that anything involved in an incident needs to be immediately taken to EBME.”

She explained that if they had been aware of the circumstances, it would have stayed at EBME.

Ward manager Jayne Simpson said she “would have stated” that the machine was “related” to an incident due to the “severity of the situation”, and that it would be “unusual” to request data unless it was related to an incident.

However, when asked whether she specifically said whether it was related to a patient death, she said she did not “recall” the conversation.

According to an email from Ms Stanton on April 28 a colleague came back to collect equipment but part of it was not quarantined and was “taken from a patient’s bay”.

Mr Butler says that “in hindsight” it could have been managed better.

Miss Green brought up the issue of whether the parameters for Louella’s condition and age were set properly, given that no alarms sounded.

Assistant divisional nurse director Faye Chadwick, who created the serious incident report, said that “all nurses confirmed they didn’t check parameters as part of emergency checks”.

Bridget Thomas, nurse director of the Family Care Division, says that from the records and information she looked at that there was a patient who used the cubicle, but that they were “not attached” to the same machine.

But when questioned by Miss Green, Miss Thomas said she “can’t be certain” if a patient was attached to the same machine before being collected for a second time.

Miss Chadwick said that a number of changes have been made to address concerns raised during the serious incident report and following the inquest.

Patients in separate rooms in the HDU will now be cared for with one to one care.

Leaflets have now been 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.

She said: “We took a lot of learning from the inquest, to learn if anything may have been done wrong.

“The position I have from the evidence I have heard is that there seems to be a lack of full understanding of how these monitors work and how they give back the information they are expected to give back.”

More “in depth training” has also been given to nursing staff in the use of the HDU machines.

Prof Pollard warned Miss Chadwick that he would issue a regulation 28 order if changes weren’t made to the serious incident report.

Miss Chadwick says that they would update the serious incident report to include note taking for parameters, and the quarantining process, as well as other changes to be made.

Alan Bridge, critical care clinical director of Alder Hey Children's Hospital, where Louella was previously cared for, issued a statement explaining that she had been discharged in line with the trust’s policies and was given the correct information to process her release.

This was following on from evidence previously heard from the Royal Bolton Hospital that this had not been carried out correctly.

Prof Pollard adjourned the inquest for reasons he was not “prepared to share publicly”.

Addressing the family, he said: “I am adjourning the inquest for reasons I am not prepared to share publicly.

“You have an expert legal team who will explain there are valid reasons.

“I have heard all the evidence in great detail as you know.

“When we come back to court next, we should be able to move straight on.

“I am so sorry we are delaying, and we are going to have to again.

“I anticipate it will be some time away.”

A date is yet to be confirmed for the inquest to continue.

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