Senior doctor tells inquest into death of Portsmouth baby that case 'should have been referred to him'

A DOCTOR investigating the death of a newborn baby told an inquest the case ‘should have been referred to him’.

Wednesday, 6th November 2019, 9:14 am
The Coroner's Court in Guildhall Square, Portsmouth

But Queen Alexandra Hospital doctor Saumitra Sengupta, who investigated the death of Albert Knight on June 25 last year, concluded the baby’s death was due to his ‘small’ size and home birth.

Parents Charlene and Matthew Knight held Albert in their arms as he died a week after his early birth, where he was delivered feet first while not breathing, having suffered brain damage.

Dr Sengupta insisted doctors were not at fault for the baby’s death after scans showed ‘normal growth’ but he admitted that while duty registrar doctor Joseph Uzokwe had executed a ‘fantastic care plan’ for Ms Knight he should have informed a senior consultant about doubts he had over whether to admit her.

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‘It’s unfortunate the registrar did not come and talk to me,’ he said.

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When asked by coroner Lincoln Brookes what lessons could be learnt, Dr Sengupta added: ‘For any high-risk pregnancy the registrar now needs to tell a senior consultant and not take it all on their shoulders.’

Despite concerns over a sudden lack of foetal movement Ms Knight was sent home and booked in for a Caesarean before going into labour just three days before the procedure was due.

‘Ms Knight came to see the registrar when she was 37 weeks pregnant but had I been involved I would have booked a C-section for 38 weeks and not 39 weeks,’ Dr Sengupta said.

Concerns over Albert’s umbilical cord and low amniotic fluid level were also not deemed serious. ‘There was no foetal distress from the CTG (scan) and no indication of labour,’ the doctor said.

Dr Sengupta, summing up why he thought Albert died, said: ‘It’s a very unfortunate incident. It was a small baby and delivery was at home with it a breech birth.

‘There was no reason for Ms Knight to be admitted.’

Independent medical expert, doctor Jillian Connor, agreed there was no need for Ms Knight to be brought in for an early Caesarean.

‘The baby was on the 10th centile with its CTG scan documenting movements so I felt it would be appropriate to monitor her daily but I don’t think she needed to be an in-patient,’ she said.

But Dr Connor conceded there ‘should have been consultant oversight’ over Albert to execute ‘what the plan was for the timing of delivery’.

Mr Knight, questioning the expert, asked: ‘What went wrong if there was nothing on the scan and then the next morning my son is effectively dead?’

Dr Connor replied: ‘There was nothing suspicious showing. There was nothing to show (Ms Knight) was in labour.’

The consultant admitted there were different medical views on what action should have been taken.

Another independent expert who looked at the case, professor Christopher Rees, highlighted Dr Connor’s point by disagreeing with her about whether Ms Knight should have been admitted earlier for a Caesarean. 

‘If Albert was not moving so well then that is significant,’ he said. ‘I would have had a heightened sense of nervousness about this pregnancy.’