Doctor did 'everything he could' to help baby who died after being given overdose of medication , inquest hears

Two nurses also described how an overdose of atracurium was administered to Polly Ida Lindop while they worked with an unfamiliar piece of apparatus

A doctor who cared for a baby who died just 24 hours after being born has told an inquest he 'did everything he could' to save the child.

Kimberley Lindop gave birth to Polly Ida Lindop at Saint Mary's Hospital in March, 2023. Yesterday (June 9), an inquest was told how the youngster was given ten times the recommended amount of an anti-seizure medication in the run up to her death.

She had described scenes of chaos on the ward before her daughter, who was born 10 weeks early, passed away.

Today (June 10), the inquest into her death at Manchester Coroner's Court heard from a doctor who cared for Polly during her short life. Two nurses also described how an overdose of atracurium was administered to Polly while they worked with an unfamiliar piece of apparatus.

Dr Gareth Penman, a consultant neonatologist, told the coroner that “a lot happened” in his 14-hour shift, and that shortly after her birth, the youngster was placed on “respiratory support”.

She had showed signs of “deterioration” as the day went on - and received multiple rounds of medication such as penicillin and gentamicin to help her with her oxygen levels, blood flow and breathing.

Despite the medication, the court heard how Polly showed little sign of improvement.

Dr Penman said that at some point during the evening of March 13, Polly began exhibiting signs of an “infection”, with two examples being a rash and the need for respiratory support.

He told the court that he had previously told Polly’s mother, Kimberley Lindop, that the rash may be due to a “birth mark” but also could be signs of a possible “infection”.

At that time, Dr Penman said he 'couldn't remember whether or not he knew for definite at that stage' if she had an infection.

He told the court that in the early hours of March 13, 2023, Polly’s condition began “deteriorate” as her blood pressure and oxygen levels fell to low levels.

Dr Penman said he had “done everything possible” to help her, and called a colleague to “bounce ideas” and ask for further advice. He explained that since the beginning of his shift, Polly’s condition had caused him “anxiety and concern.”

The court heard that after “trying everything he could” he ordered new medication of morphine, dopamine and atracurium for Polly, adding that transfusion and checks were the “responsibility of the nursing staff.”

At around 6:40am, just six minutes after Polly had incorrectly been given a dosage of atracurium 10-times the recommended amount, Polly suffered her first “collapse” which was also referred to as a “cardiac arrest”.

Dr Penman explained that, while it wasn’t a formal “cardiac arrest” as her heart was still beating, she required urgent care similar to CPR.

Following Polly’s death, Dr Penman told the court: “I don’t think Polly would have survived, even if she hadn’t received a ten times dose of atracurium".

He then apologised to the family for failing to disclose the dosage of atracurium in a first reports submitted to the coroner, stating that he was “focusing” on other factors that may have lead to her death - such as her infection.

The doctor added that it was not his intention to make it seem like he was “hiding something".

Fahima Begum and Akila Pandoor were neonatal intensive care nurses on duty at Saint Mary's Hospital on March 13, and provided the infusion of atracurium to Polly, who was described as needing "time critical care"..

During the inquest, both were confirmed to have been "separately allocated" to care for their own "very poorly baby” on the unit.

Both said that they didn’t feel any “pressure” to provide the medication. Pandoor told the court that the pair took their time “to make up the right medication” to make sure they got it “right.”

Begum went on to explain to the court that there are two pumps that were used for transfusions. While both were “identical to each other” they had different interfaces, and “you wouldn’t know which one is which until you turned it on.”

She told the court that she recalled stating that “this doesn’t look right” when she began using a pump they found, and when she couldn’t find another that the pair were more familiar with, they settled on using the apparatus available to them.

According to Begum, she inputted the correct dosage and administered the atracurium to Polly. Pandoor confirmed that she was present when this occurred.

However, both nurses accepted the pump data that showed an over-dosage was correct and accepted that it was administered six minutes before Polly’s first “collapse”.

Begum also accepted that “two opportunities” had been missed to find the over-dosage of atracurium. However, she stated that the checks were the responsibility of Polly’s caring nurse, which she nor Pandoor were.

The inquest continues tomorrow.