Pressurised air interruption led to death of 'fighter' Jackson Pickup

Evidence was heard at a continuing inquest at Accrington Town Hall, which began on Wednesday, of how Jackson Pickup died when he was five months old after an interruption of pressurised oxygen support.

Today, May 12, Coroner Richard Taylor said Jackson was a "fighter" and commended the parents for battling to bring Jackson’s case in front of the coroner after it was originally listed he had died of natural causes.

Returning a narrative conclusion, Mr Taylor said: “Jackson Stephen Thomas Pickup, who was born with a significant heart defect, died at the Royal Blackburn Hospital on December 17, 2016, from complications of his condition to which a major contributing factor was the interruption of his pressurised oxygen support on the day of his death.

“Insignificant checks having been carried out on the support equipment which was left in the care of a member of staff untrained in its operation.”

When Jackson was born on July 19, 2016, he had already been diagnosed with hypoplastic left heart syndrome, a condition in which only one of his heart chambers was pumping blood to his body and lungs.

MORE: Baby not given oxygen for several minutes in hospital before death

Yesterday, the inquest heard how Jackson was given an operation at Alder Hey on his heart and suffered a number of health worries including a case of bronchiolitis, Jackson was rushed by his mother Caroline to Royal Blackburn Hospital in the early hours of the morning on December 15.

After he arrived, he was clearly very poorly with bronchiolitis and care began at the hospital with a phone call made to Alder Hey about his condition.

Dr Chris Gardner, consultant paediatrician for East Lancashire Hospital Trust, said he believes Jackson was in the right place that day for his care.

Speaking today (May 12) in the inquest, Dr Gardner said: “He was very unwell.

“To answer the parent’s question of whether they should have just taken him to Alder Hey, I think he would have died on the way.”

He showed signs of improvement and deterioration during his stay and was put on a CPAP machine, with the inquest told by an expert witness, Nurse Nina Griffiths who reviewed the case, that Jackson’s level of care at this point was what she would have expected.

Jackson Pickup spent the first few months of his life at Alder Hey hospital. (Photo credit: Rodhullandemu)

On December 17, the nurse caring for Jackson went for their lunch and left him in the care of a nurse, Peter Doyle, who was not fully trained on the machine.

While Mr Doyle was in the room, Caroline noticed that Jackson’s CPAP machine, which had not been checked, was not humid.

The nurse went to fill up the water in the humidifier when suddenly an alarm sounded and the machine stopped delivering positive pressured air.

Coroner Richard Taylor asked: “Is it accepted by the trust that the interruption of the air flow from the CPAP machine could have been avoided?

Dr Gardner replied: “Yes, the trust would accept if the checks had been done, then the humidifier wouldn’t have ran out of water which means the covering nurse wouldn’t have been in the position they needed to refill it.

“We accept that cascade of events led to the humidifier needing to be refilled by someone who was not trained.”

He went to call for help and Sister Maxine Buckley came into the room and started looking into the machine, meanwhile, Jackson was without oxygen.

After around three minutes, when she realised she couldn’t fix the machine at that time, Sister Buckley gave Caroline a mask attached to an oxygen tank to allow her to give oxygen to her son.

Dr Philip Chetcuti, a consultant paediatrician who looked over Jackson’s case after his death, described the five-month-old as fragile and that he had a “mountain to climb” but added, on the balance of probabilities, he would have survived and gone home had the machine remained working.

Accrington Town Hall

The family barrister, Andrew Bridgeman, asked: “Should they have treated Jackson or the machine?

Dr Chetcuti replied: “Jackson.”

Dr Gardner said the first priority should have been the child, however, if staff can repair the machine quickly to keep the child on positive pressure air, that should also be explored.

Dr Chetcuti added: “He [Jackson] was just about holding his own with the CPAP support.

“When he was taken off the CPAP, which had to happen for whatever reason the machine wasn’t working, he lost the positive pressure and it wasn’t working.”

Two doctors came into the room and after checking Jackson, said he needed to be resuscitated.

Mr Bridgeman asked Dr Chetcuti: “Once Jackson had this respiratory event, his chances of survival would have been slim?

Dr Chetcuti replied: “Yes.”

Mr Bridgeman then asked: “If they hadn’t had the lack of humidity, hadn’t had the CPAP crash, hadn’t had no air support for at least three minutes until an airbag was used, he would have survived?

Dr Chetcuti replied: “He would have survived, that day, yes.”

The team managed to get Jackson back and discussions began to intubate him, with Steven and Caroline able to see their son before he was taken to an operating theatre.

A nurse came to get the parents to say it “wasn’t looking good” and took them to see Jackson who was again being resuscitated.

Dr Dennis Corbett came out, with Caroline saying that he told them they will need to do an investigation, at which point she had to stop him to ask if Jackson had died, however Dr Corbett said this was a misunderstanding.

His cause of death was determined to be cardiorespiratory arrest contributed by bronchiolitis, hypoplastic left heart failure and the general ill-health of Jackson. This was attributed to the issue with the CPAP machine.

Helen Campbell, Assistant Director of Nursing for Paediatrics at East Lancashire Hospital Trust, said a “rigorous overhaul” of the children’s high dependency unit ward, where Jackson had received his care, had been taken with “further training for nurses and more intensive checklists to ensure that an occurrence like this does not happen in the future”.

She said: “I think a lot of lessons have been learnt from Jackson.”

Summing up, Mr Taylor said: “It is accepted on behalf of the trust that the CPAP machine stopped working for whatever reason; that deprived Jackson of the pressured oxygen he so desperately needed and led to the deterioration in his condition.

“He recovered from that - with a very small 'r' - in that he was resuscitated.

“We know that was effectively the start of the end, as has been accepted. He died shortly after from another coronary event.”

Executive medical director at East Lancashire Hospitals NHS Trust, Dr Jawad Husain said: “Our thoughts are with Jackson’s family today as they continue to grieve for their son and face the difficult task of trying to come to terms with what has happened. It is clear the Trust made mistakes in caring for Jackson and I want to both acknowledge and sincerely apologise to them for that. I would like to add that significant improvements have now been implemented as a result of Jackson’s death.”