Sepsis baby Charlie Jermyn died after 'care failures'
A baby died of sepsis after failures and inadequate care by midwives, a coroner has ruled.
Charlie Jermyn, who was 30 hours old, died last May in Cornwall after healthcare staff failed to pick up on the signs of sepsis, the inquest heard.
Coroner Emma Carlyon concluded Charlie died from natural causes contributed to by a sequence of failures.
His "devastated" parents, Mark and Hayley Jermyn, say they feel angry and let down.
They are now seeking reassurance from Health Secretary Jeremy Hunt that the coroner's recommendations are implemented across the country.
The coroner said she accepted evidence from experts in midwifery, who told the inquest the midwives involved had shown failures, but that they were kind and compassionate.
Dr Carlyon said: "The Royal Cornwall Hospitals Trust should be commended for the quick implementation of a training programme."
She also said she would write to NHS Kernow to express her concerns that midwives cannot access medical records.
She said "no individual is to blame - the systems need to be improved".
In a statement released on their behalf, the family said they were satisfied with the verdict.
The statement said: "They believe Charlie was let down by significant system failures at the Royal Cornwall Hospital Trust to train and equip their midwives to take and record a baby's vital signs and recognise and act on the 'red flag' signs of sepsis, including respiratory grunting, which resulted in missed opportunities to save Charlie's life.
"When the family did as they were advised and sought help from an out-of-hours helpline their call for help was handled by an unqualified maternity support worker who, through no fault of her own, stood no chance of remotely diagnosing vital symptoms of sepsis.
"That helpline was Charlie's final safety net, and it failed."
The statement adds: "Mark and Hayley are now seeking a personal assurance from Health Secretary Jeremy Hunt that as soon as the coroner's recommendations are published about the diagnosis and treatment of sepsis, they are implemented in full throughout the country. "
Charlie was found to have died of brain damage due to pneumonia and sepsis.
Sepsis happens when the body's immune system goes into overdrive.
Expert witness Dr James Gray told the inquest he believed Charlie would probably have survived if he had been sent to hospital early enough to receive antibiotic treatment.
Consultant midwife Julie Frohlich told the inquest several parts of the care Charlie and his parents received were inadequate.
Christine Perry, director of nursing at the Royal Cornwall Hospital, said: "It is evident that opportunities to identify Charlie's illness were missed and we apologise unreservedly for the shortcomings in his care."
Last month, Mr Hunt apologised to another woman from Cornwall for failures in the NHS, following the sepsis death of her one-year-old son.
- Sepsis is when the body's immune system goes into overdrive in response to infection
- This can cause organ damage, shock, and eventual death
- Sepsis is known as a 'silent killer' because it can be difficult to identify
- It is common - it is the second biggest cause of death after cardiovascular disease
- It can arise as a consequence of a variety of infections - the most common sources are the lung, and urinary tract
- Sepsis can affect people of any age, but is most common in the elderly and the very young
- Signs of sepsis include fever, breathlessness, shivering and mottled or discoloured skin