Finnley Morris: Blackpool town hall inquest hears evidence of further delays in treatment of baby who died of brain injury due to lack of oxygen
Evidence of further delays in the care given to a critically ill newborn, who later died of a severe brain injury, at Blackpool Victoria Hospital have emerged in the investigation into the infant's death.
Finnley Morris suffered a hypoxic brain injury as a result of being starved of oxygen for a long period of time around the time of his birth at Blackpool Vic on October 1 2020. He was transferred to the Royal Preston Hospital, where he died on October 5.
An ongoing inquest at Blackpool town hall this week heard evidence of a series of delays in the care given to Finnley as medics attempted to resuscitate him.
When paediatric consultant Dr Sunitha Peiris arrived at the scene 30 minutes after Finnley was born, she was shocked to find the baby - who she said was 'floppy, with no signs of spontaneous breathing' - had not already been intubated by medics, who were applying ventilation breaths and chest compressions.
Coroner Alan Wilson asked Dr Peiris: "Quickly on arrival, having had the chance to check on Finnley, you were clear that this was a baby that needed intubating, correct?"
She replied: "Yes."
However, a slight delay followed as Dr Peiris could not find her reading glasses, which she needed to carry out the procedure, and she asked the nurses if any of them had a pair she could use.
The registrar, Dr Suriya Dhulipala, volunteered to intubate Finnley instead. She said: "I immediately volunteered because I was confident I could do it."
There was then a delay of approximately three minutes, as a clamp was missing from a tube on the resuscitaire, a device used to aid the resuscitation of newborn babies.
Victoria Beel, representing Finnley's family, said: "Do you think that you should have intubated without the clamp in that situation?"
Dr Peiris said: "Yes. The clamp is necessary to hold the tube in position. When they pointed out there was no clamp, I didn't think it would take them so long to find it. It took about three minutes."
She added that she 'did think about putting the tube in without the clamp', but decided not to.
Ms Beel said: "Do you think that was the right decision?"
Dr Peiris replied: "Maybe not."
Following the first intubation by Dr Dhulipala at 1.04am, 42 minutes after birth, Finnley's condition did not improve.
Nurse Hayley Knighton said: "I didn't feel I could see the chest rising when they did the ventilation breaths. I think I said two or three times that I couldn't see the chest movement.
"There was feeling, I think, from the doctors that the tube was in place and from what I could see I wasn't sure that was the case."
Eventually, the tube had to be removed and replaced by Dr Peiris. Further time was wasted as medics tried to locate a fresh tube, with Dr Peiris eventually deciding to reuse the same tube after a new one could not promptly be found.
In a later investigation by the Healthcare Safety Investigation Branch, when asked if she thought there was good leadership present during the resuscitation process, Ms Knighton said: "No I didn't. I knew that the consultant was en-route and I asked if she was nearly here. I asked the registrar if the wanted anyone else calling because I just felt like she needed someone else. I felt like that would push things forward or take control of the situation.
"I just felt like we needed somebody to do that. I felt quite - vulnerable isn't the right word - but I didn't feel comfortable. I just felt like in past experience there has been directions given by someone there who has been reading the situation, and I didn't feel like that was happening."
Independent expert Dr Malcolm Griffiths, a consultant obstetrician who examined Finnley's birth, said he had 'no criticisms' of the care around the delivery of the baby.
He said Finnley 'had a low heart rate when he was born, and clearly something has happened to him' which led to him being deprived of oxygen for a long period of time.
The inquest continues.