Kettering baby’s catastrophic injuries could have been prevented had fractures been spotted

Kettering General Hospital

Kettering General Hospital

  • Serious case review says opportunity missed to take child into care earlier
  • Lack of specialist meant X-ray was misinterpreted
  • Parents were jailed for abuse last year

Catastrophic injuries which a Kettering baby suffered at the hands of her parents could have been prevented had earlier rib fractures been noticed, a case review has found.

Baby Isabelle suffered life-changing abuse during the first five weeks of her life in 2014, which led to her parents Rocky Uzzell and Katherine Prigmore being jailed in December.

A serious case review published this afternoon (Thursday) by the Northamptonshire Safeguarding Children Board revealed its findings after the subsequent investigation into her injuries.

Isabelle - termed as Child N in the report - was admitted to hospital six times in her first five weeks of life before her parents were eventually arrested.

On March 6, 2014, her parents called 111 and mentioned that she was suffering leg pain.

She was discharged from hospital on March 8 but the following day was re-admitted after her parents said she went ‘blackish-purple’ in the face and stopped breathing for a few seconds.

After observations, no further incidents were seen so she was discharged.

On March 12 she was taken to hospital again after Uzzell called 999 when he found her unresponsive and ‘going limp’.

The 999 call handler reported hearing piercing screaming on the phone.

Isabelle was given fluids and antibiotics at hospital for a suspected infection.

The following day Isabelle had her chest X-rayed at Kettering General Hospital, and it was at this point that her further injuries could have been prevented.

Isabelle had suffered two rib fractures but the ward review said the X-ray showed ‘patchiness’ of the left lung, with a decision made to discharge her.

Had those rib fractures been identified, she would have been taken out of her parents’ care there and then.

The serious case review report said: “If the rib fractures had been identified in the X-ray, this would have triggered a safeguarding response and, most likely, Child N would not have remained in the care of her parents, and not suffered subsequent catastrophic injuries.”

Isabelle was later admitted to hospital on March 20 where her condition deteriorated so much it was thought she wouldn’t survive.

On March 21 specialist imaging was carried out which revealed she had an inter-cranial bleed, potentially as a result of abuse.

The injuries, which also included a broken leg and fractured wrist, left her unlikely to ever walk or talk and with severe disabilities.

KGH was without a specialist paediatric radiologist, and the fractures were not noticed on the X-ray by other members of the medical team.

The report found: “Child N’s X-Ray films during her admission were reviewed and reported by members of the radiology department who were general radiologists, rather than radiologists with specialist paediatric expertise or a paediatric interest.

“Previously, there had been a radiologist with paediatric special interest at the hospital but he had retired and no-one with equivalent expertise could be recruited, despite repeated attempts to obtain this expertise.

“This position is not apparently unusual in smaller general hospitals, and there is a recognised shortage of paediatric radiologists nationally.

“There was a missed opportunity during this admission to identify non-accidental injury.”

The report also revealed that despite six hospital admissions in five weeks, none of the incidents were linked – leading to each being treated as a ‘new’ issue.

The review found: “There was no system in the hospital for ensuring that the information and outcome from each admission was collated in a single record or chronology of episodes of care and, as a result, it was not possible to see any

possible pattern.

“At each admission, the medical team were in effect “starting again”.

“On each occasion the search began anew to seek medical or congenital reasons for Child N’s condition.”

There was also criticism of hospital staff’s readiness to accept the parents’ explanation for the injuries, rather than consider non-accidental injury, and their apparent medical knowledge.

Prigmore said Isabelle’s leg pain may have been down to hip dysplasia, which she had suffered from as a child.

The review found this was too readily accepted and not fully researched.

When Isabelle was admitted after she stopped breathing, the parents were shown how to give life support if it re-occurred.

They said they already knew how but this was not questioned.

The report also highlighted gaps in information-sharing surrounding the parents’ mental health prior to Isabelle’s birth which could have led to a referral to children’s social care.

Uzzell had a history of neglect, was sectioned, heard voices and fathered a child with a girl aged 15 but had no contact with her.

Prigmore had ADHD and a history of depression, a fact which she had shared with the midwife.

But neither parent shared their childhool difficulties or the fact that Uzzell already had a child.

The midwife saw them as vulnerable and likely to need additional support, but no health professionals contacted mental health services to find out their history.

The review found: “There was significant and relevant history in relation to the likely parenting capacity of both parents and possible vulnerabilities.

“Unfortunately, the level of safeguarding concern was not reached which might have led to referral to children’s social care.

“The fact that mother and father themselves withheld some relevant information and seemed to be coping and committed to the baby also is likely to have led professionals to take an optimistic and less inquiring approach.”

The report’s author, Amy Weir, has made a number of recommendations for the board to consider and action in the wake of the case including:

• To review how joint working can be improved between acute hospitals, children’s social care and the multi-agency safeguarding hub (MASH) when non-accidental injury is suspected

• That all practitioners ensure fathers, and their history, are fully factored in during their work with families.

A number of measures have been put in place since the originalcommissioning of the report in 2014 including:

• KGH has now acquired a limited amount of paediatric radiology expertise which was lacking at the time

• The paediatric liaison service has been reviewed and changes put in place to ensure it reports on emergency admissions

• A new NSCB protocol/toolkit has been launched on unexplained bruising in young babies.

Neither Uzzell or Prigmore participated in the review of the case at the time, saying they were too pre-occupied with care and criminal proceedings.

Isabelle is now in care outside the county.

Uzzell was jailed for six years, with Prigmore given two years and four months behind bars.

KGH: “We profoundly regret the missed opportunities to escalate safeguarding concerns”

Kettering baby abuse case one of the most serious I’ve dealt with, says safeguarding board chairman