Inquest told 'lessons can be learned' from failed attempts to save premature baby at QA Hospital

Medical staff were unable to insert a ventilation tube into Anastasia Ciocirlan at Queen Alexandra Hospital after the infant was born with a twin at just 23 weeks in March last year.

The baby passed away after 17 days on April 3 despite initially making ‘steady progress’ after having to be resuscitated at birth.

But Anastasia, who was treated to QA after being transferred from Dorset because of the hospital’s 65 per cent ratio of saving premature babies compared to a national average of between 30-40 per cent, developed bronchopneumonia and sepsis which she was unable to fight-off due to her ‘decreased physical reserves’.

Dr Samantha Holden, paediatric pathologist, told Portsmouth Coroner’s Court: ‘Anastasia was very small and extremely premature which led to her having limited physical reserves to fight-off things.

‘She had bronchopneumonia and inflammation in her lung. There are complications of having premature babies.

‘Had she been an infant who was not so premature then she might have been ok but because she was so small and premature she deteriorated.’

The baby’s mum Katarina Marinelos questioned whether the lung deterioration and sepsis could have been avoided in the days after birth.

‘Portsmouth has a track record of treating babies in gestation with a 65 per cent record of survival compared to a national average of 30-40 per cent,’ Dr Hew Price-Jones, who had treated the baby while on duty, said.

‘It is a very tricky thing to manage and you have to get a lot of things right.’

Asked whether being given antibiotics earlier would have made a difference, Dr Price-Jones said: ‘It’s impossible to answer. They started the following day but it is difficult to know the right course of action.’

Following Anastasia’s death an investigation was launched by the hospital to see if anything could have been done differently, especially after five unsuccessful attempts to put a ventilation tube back into the baby failed after doctors had decided to remove it with the infant showing signs of improvement.

Dr Price-Jones said: ‘It is difficult to get the right spot (inserting a tube) as there is not one single reliable way of doing it.

‘There were some limitations with the equipment size due to the baby being so small and there were human factors. There are a number of lessons to be learned.’

Coroner Samantha Marsh was confident QA had taken necessary steps to make sure there were no issues in the future regarding extremely premature babies but conceded nothing would have prevented Anastasia’s decline.

Recording a narrative verdict the coroner said: ‘Anastasia died from bronchopneumonia which developed as a result of essential artificial ventilation on a background of decreased physiological reserves which were already compromised by extreme prematurity having been born at 23 weeks.’

Anastasia’s sister survived the premature birth and is in good health, the court heard.