Northampton General Hospital's mistakes led to tragic death of nine month old baby girl, inquest finds

Northampton General Hospital made multiple mistakes which led to the the tragic death of a nine-month-old baby, an inquest has found.

Iona Grace Buckingham was admitted to NGH on November 28, 2022, because she had trouble breathing and needed help with feeding.

Despite an initial improvement in her condition, a distressing turn of events on December 3, 2022, led to an upgraded level of respiratory support. A subsequent chest x-ray on December 4, 2022, revealed severe complications, and attempts to rectify the situation resulted in an accidental extubation, ultimately leading to Iona's death. She sadly died at 6.37pm on December 4 2022.

Investigation and Inquest

Assistant Coroner for Northamptonshire Jonathan Dixey, overseeing the investigation and inquest, has this month (January) presented findings that shed light on missed opportunities and systemic issues that possibly contributed to Iona’s death.

The investigation, initiated on December 14, 2022, concluded on January 10, 2024, with a narrative conclusion stating that Iona Buckingham's cause of death was bronchopneumonia with empyema (a severe lung infection) due to invasive Group A streptococcal infection. The inquest highlighted critical junctures where medical interventions, such as the administration of clindamycin and timely chest imaging, were overlooked, potentially contributing to Iona's death during an accidental extubation on December 4, 2022.

Coroner's Concerns

Assistant Coroner Dixey expressed grave concerns during the inquest, identifying potential risks for future deaths if corrective measures are not implemented. Notably, the coroner highlighted the hospital's limited access to a paediatric radiologist, particularly outside regular working hours, posing a substantial delay in crucial diagnostic procedures for critically ill children.

The coroner said: “I am concerned that a very unwell child who may require a chest ultrasound may not receive one ‘immediately’ and in fact may have to wait for a considerable period of time. For example, if the need arose over a weekend, that child may not receive an ultrasound scan for up to 48 hours.

"I understand a reason why Northampton General Hospital does not have access to a paediatric radiologist outside of 9am-5pm on Mondays and Fridays may be due to the funding that is available.”

Immediate Action Needed

The assistant coroner has forwarded his concerns to Northampton General Hospital NHS Trust, NHS Northamptonshire Integrated Care Board, and NHS England, urging immediate attention to address the identified risks.

Assistant Coroner Dixey said: "I am satisfied that the Trust has taken action in respect of the recommendations made and more broadly have reflected upon the circumstances of Iona’s death. However, in respect of the recommendation set out above, I am concerned that there remains a risk that future deaths could occur unless further action is taken.

“Action should be taken to prevent future deaths, and I believe you have the power to take such action."

Hospital's Response

In response to the coroner, a Northampton General Hospital spokeswoman said: “We are deeply saddened by the death of Iona and our thoughts remain with her family. We are reviewing the recommendations from the coroner and will be responding within the specified timeframe. We are working closely with all system partners across Northamptonshire to discuss the findings and will work together to assess and implement any actions that can be taken.”

Click here to read the full report into Iona’s tragic death.