Cassian Curry was born on 3 April 2021 at the Jessop Wing of Sheffield Teaching Hospitals Trust and sadly died on 5 April 2021 in the neonatal intensive care unit at Jessops. The four day Inquest into Cassian’s death took place at the Sheffield Medico-Legal Centre and the conclusion was handed down by Assistant Coroner, Abigail Combes, on 22 April 2022.
Cassian was born prematurely at 28 weeks gestation. Despite being premature his clinical condition was consistently described as strong in the medical records and in evidence obtained by the Coroner.
A few hours after his birth Cassian was fitted with an Umbilical Venous Catheter (UVC), essentially a feeding line, through which he was meant to receive nutrition for the first few days of his life.
The UVC was placed in what the Trust described as a “sub optimal” position and the tip of the line was within the cardiac silhouette. Evidence heard at Inquest claimed it was reasonable to leave the UVC in that position for a short period of time but that there should have been a documented plan to review its position and withdraw the line within 24 hours due to the risk of the nutritional solution filling the pericardial sac and causing a cardiac tamponade, which would stop the heart beating, and lead to death.
The Coroner heard evidence that the tip of the line may have been within the right atrium of the heart. Despite some clinicians being aware of the suboptimal position of the line a consultant signed off a checklist to note it was in a satisfactory position when it was not. Another clinician reviewed x-rays the following day and noted the discrepancy, discussing it with the same consultant. No further action was taken to review and move the line and medical records were not updated with a plan or to clarify the true positon of the line. The Coroner heard evidence that the consultant “forgot” about it.
Tragically, Cassian did develop a cardiac tamponade in the early hours of 5 April 2021 and, despite resuscitation attempts, he died shortly thereafter.
The Coroner highlighted serious failings at the Trust in terms of record keeping and communication, concluding that they led to Cassian’s death. She also made a finding of neglect – a gross failure to provide basic medical attention – which is not common in cases of this nature.
The Coroner heard evidence from the Trust on the changes they had made as a result of Cassian’s death but she did not think they went far enough and she will be issuing a Prevention of Future Deaths report. At present we understand that report will include reference to communication with parents, staffing levels and pressure on the Jessop Wing as a centre that supports the region with neonatal admissions and transfers.
Following the Inquest conclusion Cassian’s parents, James and Karolina, made the following statement:
“Cassian was a beacon of light and our hearts blossomed under his pure and innocent love. He was everything that we dreamed of. Today the Coroner concluded that he died because of neglect and had it not been for the gross failings of those in charge of his care, he would still be with us today. Cassian was a true miracle, and we will love and miss him forever”.
“Cassian’s death was avoidable. He was a strong baby who should have gone home with his parents, who had tried for years to start their family after multiple failed IVF attempts. James and Karolina have sat patiently and listened to the evidence at Inquest, re-living what happened to Cassian. They have some answers but nothing can lighten their grief over what happened and, more importantly, how it happened. James and Karolina want to make sure the Trust makes changes so that no other family has to go through this”.