Ineffective care "contributed" to baby Jack's death

Friday 18 January 2019

Baby Jack Tually died in 2014 because he had hypoxia, which was caused by a circulatory problem that can sometimes occur in newborns.

A three hour period where Jack was ineffectively intubated by a paediatrician also contributed to his death just 14 hours after he was born.

These were the findings of Judge Philip Robey, who has spent the last week overseeing the inquest into the death of baby Jack.

He gave his verdict on the official cause of Jack's death this morning after hearing from three experts on Monday and Tuesday. They answered questions Judge Robey and a number of advocates had about the circumstances surrounding the death. 

And while this judgement should put an end to the questions surrounding Jack's death, it has taken five years to get to this point.

Pictured: Judge Robey heard the evidence presented at baby Jack's inquest at Guernsey's court this week. 

Judge Robey said: "It was not possible in this case to say why or when it [PPHN] developed, [but] in accordance with the experts' evidence, I am satisfied on a balance of probabilities that hypoxia caused by PPHN was the primary cause of death.

"Dr Ashton gave evidence about the treatment administer to baby Jack following the sudden deterioration in his condition around 06:15. Jack was intubated but the intubation was unsuccessful. A 100% leak was indicated which persisted until re-intubation was achieved around 09:40. The lack of effective intubation during that period was considered by Dr Ashton to have contributed to baby Jack's death.

"I accept Dr Ashton's opinion and find on a balance of probabilities that baby Jack's death was contributed to by the lack of effective intubation in the stated period." 

Those were the only two statements Judge Robey made with direct regard to Jack's death - he said there were no other factors he considered to have contributed to it. 

Throughout this inquest the Judge made it clear this was simply to answer the question of how baby Jack came to die, not to apply blame to any parties or decide who did what. 

Now, hypoxia will be able to be put on Jack's death certificate, replacing the previous, incorrect, statement of septicaemia that was initially thought to be the cause of death. 

To read more about this week's proceedings, click here.

To read a statement from baby Jack Tually's parents, click here. 

To read a statement from Deputy Heidi Soulsby, President of Health and Social Care, click here. 

Express will have more on this story shortly.