Baby died because Rosie Hospital in Cambridge failed to administer routine vitamin K jab
The parents of a baby boy who died from a brain haemorrhage at seven weeks old after medical staff at the Rosie Hospital failed to give him a routine vitamin K injection have spoken of their devastation.
William Moris-Patto was born prematurely at 34 weeks and five days in July 2020 at the maternity hospital in Cambridge, where it was mistakenly recorded that he had been given the jab.
An inquest held in Huntingdon concluded that had it been administered, he would not have died.
The coroner, Lorna Skinner KC, said: “The failure to administer vitamin K was a gross failure in medical care amounting to neglect.”
His parents, Naomi and Alexander Moris-Patto, from Chatteris, are now raising awareness of the importance of vitamin K injection, which is routinely given to every newborn during health checks at birth to help blood to clot.
Babies can lack vitamin K until they begin eating solid food, usually around six months of age. Premature babies and babies that are exclusively breast-fed are particularly at risk without the injection.
William, the couple’s first child, was healthy and well until he was six weeks old, when he suffered severe and sudden sickness and increasing lack of responsiveness.
He was rushed by ambulance to A&E and found to have suffered a massive intracranial haemorrhage, known as vitamin K deficiency bleeding or VKDB. He underwent emergency neurosurgery on the same day, but his injury was too severe and the decision was made to withdraw care on September 17.
“Our little boy was the most precious thing to us, and we would do literally anything to have prevented this from happening and to have him back in our arms again,” said Naomi. “I can’t make that happen, but I can try to make sure that no other baby is put at risk because of the same omissions.”
After William’s death, the hospital raised concerns that he may never have received his vitamin K injection, even though his discharge paperwork indicated that he had.
A serious incident investigation was launched, led by external reviewer Dr Timothy Watts, a consultant neonatologist from Evalina London Children’s Hospital.
It found that systemic factors “may have led to the failure to prescribe and administer vitamin K” which “led to the tragic death of the patient”.
The external review identified a number of factors that led to William’s death, including a lack of communication between doctors and nurses, mix-ups as a result of using both paper and electronic notes, and software issues.
The coroner at last week’s inquest concluded: “William died of natural causes – a vitamin K deficiency which caused a spontaneous intra-cranial haemorrhage. His death was contributed to by neglect in that he was not given Vitamin K after birth and if he had been, he would not have died.”
Cambridge University Hospitals (CUH), which runs the Rosie, has admitted serious failings and launched an additional internal review to prevent similar outcomes in the future.
A CUH spokesperson said: “The trust remains deeply saddened by William’s tragic death and wishes to express its sincere condolences and apologies to his family at this difficult time.
“The trust thoroughly and diligently investigated the events leading up to William’s death, and fully accepts the findings of His Majesty’s Coroner.
“Processes were, and continue to be, constantly reviewed to ensure a similar error cannot be made in the future. If, following further review, the coroner has any concerns, these will be addressed.”
Alex and Naomi, 33-year-old scientists who now have a 14-month-old child, say the most stringent safeguards are needed.
“Of course people make mistakes, but hospitals need to make sure they have water-tight standards, with systems in place for double- and triple-checking, to minimise the risk of such deadly oversights,” said Naomi, who leads a research lab on human embryo development at the Francis Crick Institute. “The word ‘vitamin’ makes it sound like an optional supplement rather than the difference between life and death.”
Alex, a researcher at the University of Cambridge who has co-founded William Oak Diagnostics to test for deficiencies in babies, added: “We want people to know more about it, to understand how critical it can be, and for hospitals to take seriously the responsibility they have in those first precious hours of a baby’s life.”
Department of Health guidelines recommend that all babies are given vitamin K at birth to avoid vitamin K deficient bleeding, which can lead to spontaneous bruising or bleeding and brain haemorrhage.
The National Childbirth Trust says that between 0.25 per cent and 1.7 per cent of babies who do not receive vitamin K at birth will develop classic vitamin K deficiency bleeding, while five to seven per 100,000 babies will develop late VKDB.
If administered via an injection, only one dose is required. It can also be given orally but further doses are needed. Research suggests that approximately one per cent of parents in Scotland and up to three per cent in the US refuse the vitamin K prophylactic.