KK Hospital Considering Monitoring Newborns’ Vital Signs Until Handover After Baby’s Death
KK Women’s and Children’s Hospital (KKH) is considering monitoring the vital signs of newborns up until their handover to other teams in the hospital.
The development comes after the death of an 11-day-old infant, who passed from a brain injury in Apr 2021.
Source: Google Maps
Recordings of the baby’s vital signs were absent for some time after birth, which State Coroner Adam Nakhoda called “not ideal”.
While the baby was born at 4.30am, no vital signs were taken from the seventh minute after his birth.
The documentation only continued once a nurse brought him back into an operating theatre at 5.20am.
Unfortunately, the baby was later pronounced dead at 12.30pm on 12 Apr 2021.
Baby was born with low heart rate & blood oxygen level
Following his delivery via emergency caesarean section, the baby had three loops of umbilical cord around his neck.
According to The Straits Times (ST), the medical team removed the umbilical cord immediately and put the baby on a resuscitator.
The infant reportedly had a weak heart rate and low blood oxygen level.
As a result, a neonatal resuscitation team had to give the baby continuous positive airway pressure (CPAP) to improve his vital signs, Channel NewsAsia (CNA) reported.
Six minutes after delivery, the baby was purportedly vigorous and had a “good cry”, upon which the team ceased the CPAP.
Baby had breathing difficulties leading to seizures & blood in mouth
The doctors attending to the baby left the operating theatre afterwards for another medical emergency. They left him in the care of a senior staff nurse.
While the baby’s heart rate and blood oxygen level remained normal, the nurse allegedly observed that he had a “weak cry”.
She promptly contacted the special care nursery ward for a transfer. The nurse then took the infant off the resuscitator and brought him to the viewing room for his father to see him.
During this time, the nurse noticed the baby was limp and not breathing spontaneously.
With that, she took him back to the operating theatre and alerted the doctors.
When the baby showed no response to stimulation, doctors reportedly transferred him to the neonatal intensive care unit (NICU).
Despite being connected to a ventilator, he developed seizures and had “copious” amounts of fresh blood in his mouth.
An MRI also showed that there was swelling and bleeding in the child’s brain.
State coroner rules out foul play in baby’s death
The baby’s condition continued to worsen until the fifth day after his birth.
By the sixth day, his parents agreed to withdraw care after consideration and discussion with the medical staff.
The State Coroner ruled out foul play and determined the baby had died of natural causes, noted CNA.
An autopsy certified the cause of death as a brain injury stemming from a decrease in oxygen or blood flow.
However, there was no evidence to establish the baby’s condition before his transfer to the viewing room.
KKH stated that there was no documentation of the baby’s vital signs being monitored as he was in stable condition initially.
Nonetheless, the hospital is now looking into ensuring consistent documentation until the newborn’s handover to other medical teams.
The hospital has also informed its neonatology teams to ensure that medical personnel oversee any newborn babies in need of oxygen supplementation.
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Featured image adapted from Google Maps.
