A HOSPITAL policy on how to monitor at-risk babies has been reviewed since the death of a two-day-old boy.
Tobias Taylor's mother Marie said doctors at East Surrey Hospital refused to examine her baby until he was 24 hours old, and she took him home before he was looked at.
By the time he was brought back into hospital, 15 hours later, he was gravely ill and died the next day.
During an inquest into his death on Monday and Tuesday, midwives and doctors said it was practice for checks on healthy babies not to be performed until they are 24 hours old – because it can take that long for issues to present themselves.
But pre-birth scans had shown Tobias had echogenic bowel – a shadow which may or may not have indicated a problem – plus a dilated bowel.
Both his parents were carriers of cystic fibrosis. Together, these factors posed a risk of a blockage.
It was written in medical notes that Tobias should see a paediatrician after birth, but no further care plan was put in place.Under police interview in 2011, registrar Dr Alison Bernard said Tobias should have been checked by a paediatric doctor earlier than 24 hours.
She said: "Ante-natally it should have been flagged up that there was this history and scans etc and he should have been examined at six hours and he wasn't."
Dr Bernard also said she thought, wrongly, that Tobias had been checked by the senior house officer on duty before she saw Mrs Taylor.
In her evidence, Mrs Taylor said she had frequently requested to see a paediatrician following Tobias's birth on May 17, 2009.
The midwife on duty told the inquest that this was because she wanted to go, not due to a particular concern about the baby's health. Mrs Taylor told staff she "may as well go home" after being told Tobias, who appeared to be well, would not be examined until 24 hours old.
Dr Bernard said she clearly explained what symptoms to look out for when Mrs Taylor self-discharged Tobias at 5.30pm. Mrs Taylor disputed that.
However Debbie Pullen, the consultant who treated Tobias when he returned to hospital, said: "I feel she [Mrs Taylor] was given very clear instructions about when to come back in. I do believe that had she come back at midnight when he clearly wasn't right he could have been saved.
"He was very, very unwell," she added. "He had a grossly distended, rock hard abdomen, he was in shock, he was septic."
Consultant paediatrician Ivor Lewis told the inquest at Woking Coroner's Court the system of communicating possible complications had "immeasurably improved" since the case. Any baby with echogenic bowel must stay in hospital until the bowel is functioning normally and unborn babies with potential problems are flagged up at weekly meetings.
An internal investigation by East Surrey Hospital into Tobias Taylor's death found he should have been looked at by a doctor. "There should have been a paediatric examination of him before he went home," said Michele Cudjoe, hospital risk manager. But, she said, there was no definitive national guidance on when a baby should be given an abdominal X-ray. The investigation also found the communication to Mrs Taylor was not explicit enough, and staff on the special care baby unit (SCBU) had not been told of the deterioration in Tobias's condition overnight, after Mrs Taylor phoned in to say she was bringing him back. A series of changes have since been made at the Earlswood hospital since Tobias's death. The court heard:- The system of ensuring there are antenatal care plans for babies with a health risk is 'more robust';
- The self-discharge form now contains more information;
- Any mother wanting to self-discharge must be seen by a consultant; and
- A baby being readmitted should go to the emergency or child assessment units, where they will be seen quicker than if they go to SCBU.
