AN INTERNAL investigation is to be carried out by health bosses after a coroner recorded a misadventure verdict over the death of a new born baby at Burnley General Hospital.

Two long serving nursing staff, Sister Dorothy Holgate and Staff Nurse Susan Ball have been suspended on full pay for 21 months by Burnley Health Care Trust following the death of baby Charlie Louise Taylor on January 19 last year.

East Lancashire Coroner David Smith recorded his verdict after hearing how Charlie was born with a number of congenital problems and died within 13 hours.

The inquest heard that a T-piece connector was not fitted to equipment providing humidified air and gasses to the child.

It was two days after the baby's death that the problem with the equipment was reported and a second post mortem examination was carried out. After an intensive investigation the Crown Prosecution Service decided that no criminal proceedings would take place.

Professor Anthony Milner, of St Guy's Hospital, London, said the effect of the T-piece being missing would be that 100 times more oxygen than normal would have entered the baby's body, bursting her lungs, dispersing air through her body and causing a brain haemorrhage.

He agreed the effect would have been more or less instantaneous, within two or three seconds.

He said the baby's condition was rare and the solution suggested by consultant paediatrician, Dr David Thistlethwaite, for her treatment was very reasonable.

Professor Milner said: "The message of this tragic story is that one should make sure people do know the techniques you want them to carry out and if they are not sure they should ask."

In evidence, Dr Thistlethwaite said he had no doubt that Sister Holgate knew what he wanted. The coroner said there were problems about self-incrimination and he had agreed that Sister Holgate and Staff Nurse Ball could read prepared statements.

Sister Holgate, who has been in the nursing profession for 30 years, said her memory was that after searching for the connection, it was Staff Nurse Ball who actually fitted it.

Almost immediately something went wrong and she went cold with fright and pulled out the tubing.

Staff Nurse Ball said she was not conscious that the T-piece was missing and automatically assumed it would be present.

Charlie was the daughter of Neil Taylor and Gemma Wadsworth, of Colne.

They said they welcomed the verdict but did not want to speak. They now have another baby, another daughter.

Trust spokesman, Chris Allen, said: "We will now hold an internal investigation based on what has been said at the inquest.''

He expressed condolences to the family on their tragic loss.

He said the Trust wanted to assure people in Burnley, Pendle and Rossendale that the neo natal intensive care unit and the maternity unit provided a first class service.

The Coroner said there was nothing wrong with the suggestions made by Dr Thistlethwaite to Sister Holgate.

It was unfortunate that she either didn't understand or forgot to attach the T-piece.

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