Death of our son's twin brother was preventable

Andrew Witkowski-Blunden was just two days old when he was pronounced dead at the Royal Sussex County Hospital in Brighton.

An inquest found medical misadventure caused his death after he sustained skull fractures during a traumatic birth where forceps were used around his head to try to deliver him.

His parents Edyta Witkowska, 39, and Mike Blunden, 41, described January 23 this year as the best and worst day of their lives.

The twins were born at 32 weeks but while Arthur was healthy, Andrew was fighting for his life.

After the hearing Mr Blunden, of The Ridgeway, Woodingdean, said: “By the hospital’s own admission, an error of judgement made during the delivery caused our son’s death. The tragedy is how unnecessary and preventable his death was.

“Our surviving twin will never know his brother.”

On-call consultant Jubril Ajala resorted to using forceps to try to deliver Andrew after his heart rate rapidly dropped and attempts with other instruments failed.

He pulled twice but this was also unsuccessful so the team was forced to carry out an urgent caesarean.

In the following hours the baby developed a haemorrhage causing his head to swell rapidly. There was bleeding between his skin and skull and on his brain.

He died just after 8pm on January 25 in the hospital’s Trevor Mann Baby Unit.

A post-mortem found the cause of death was hypovolemic shock – when more than 20 per cent of blood supply is lost – after skull fractures were sustained during birth trauma most likely from the use of forceps.

Giving evidence at the inquest in Brighton, Mr Ajala said he made an error of judgement in how to best deliver the baby. He broke down in tears as he told the family he was “so profoundly sorry” for their loss.

Recording the conclusion, Brighton and Hove coroner Veronica Hamilton-Deeley, said communication during the delivery was “deeply flawed”.

She raised concerns about decisions to stray from protocols and failure to fully obtain consent for an instrument-assisted birth, adding: “I simply cannot see why time wasn’t taken to consider what was going on. I remain unclear as to the rationale behind the decision.”

The hospital has since put a number of measures in place to prevent another death.

Mr Blunden said: “All we hope is that the changes are implemented so no one ever has to go through what we have been through again.”

'WE HAVE BAD DAYS BUT ARTHUR KEEPS US GOING'

ARTHUR cuddled up to his critically ill brother Andrew in the only half an hour they were able to spend together. 

The pair of babies were pictured nestled in an incubator by their parents Edyta Witkowska and Mike Blunden.

They hope the picture will be a lasting memory as Arthur grows up without his twin. 

Mr Blunden said: “It was such a lovely moment but also incredibly sad.”

The image shows the extent of the swelling on baby Andrew’s head which, even though he was an hour younger than his brother, makes him look almost double the size. 

Mr Blunden said: “We managed to have some time with Andrew. 
“He was in a coma the whole time but he will always be our baby boy. 

“He looked quite a lot like Arthur which was nice but that also makes it so sad. 

“We put them both in the incubator together for half an hour and Arthur cuddled up to him. 

“It was lovely to see but it was also so sad.”

Ms Witkowska went into labour on Saturday, January 21, some eight weeks early.

She rushed to the hospital with her partner Mr Blunden and was given several epidural injections to ease back pain.

After little progress with contractions for more than 14 hours, staff contacted the on-call consultant Jubril Ajala who decided to go to the hospital and prepare for a caesarean section. 

But Ms Witkowska was eager to deliver her twin boys naturally so they waited a little longer. 

At around 5am on January 23, Arthur was delivered naturally by Mr Ajala with the help of a ventouse machine which acts as a vacuum. 

Within an hour the first-time parents’ elation had turned to panic as the room descended into a state of emergency. 

Mr Ajala had tried to deliver second twin Andrew by the same method but the machine failed and his heart rate dropped rapidly. 

After trying another machine which also failed, he resorted to forceps. 
He pulled twice but this was also unsuccessful so the team was forced to carry out an urgent caesarean. 

Mr Blunden said: “All I can remember is instantly when Andrew’s heartbeat dropped you could sense panic in the room, the atmosphere changed. 

“Suddenly everyone sort of went into emergency mode. 

“Being taken outside and having to wait for news was the worst thing.”

Andrew was quiet, pale and only gave a “little cry” when he was born, the inquest heard. 

He was taken for immediate treatment in the Trevor Mann Baby Unit, the hospital’s special care baby unit, where his brother was already settling in well. 

Tragically, Andrew died two days later. 

Mr Blunden said he felt “complete disbelief” when he heard the news.

He said: “You never think this sort of thing could happen to you. 

“It was a strange situation – it was the best day of my life and the worst.
“I didn’t really know what to think, I was so happy because of Arthur but so sad about Andrew.”

He told how Arthur was the one who had kept the family going since the tragedy.

Mr Blunden added: “We all have our bad days but we keep going on. 
“Having Arthur is helping an awful lot. 

“He makes us very happy.”

He said despite everything they were eternally grateful to all the staff at the Trevor Mann Baby Unit.

He said: “They were fantastic. They couldn’t help him but they were absolutely brilliant in the way they cared for him.”

TRUST PROMISES CHANGE

A SERIOUS incident investigation was carried out by the Royal Sussex County Hospital after Andrew Witkowski-Blunden’s death. 

Jo Sinclair, Brighton and Sussex University Hospitals NHS Trust’s lead consultant for pregnancy care who oversaw the inquiry, told coroner Veronica Hamilton-Deeley changes had been made. 

Subril Ajala, a consultant who has practised for more than 20 years and has been with the trust since 2010, said this was the first baby he had ever lost. 

He said it was an “omission” on his part not to take time to discuss the implications of the procedure fully with the parents before going ahead. 
He insisted he had obtained verbal consent from the family and that communication with his team was “clear”.

But giving evidence Rachel Chatterton, a midwife of seven and a half years overseeing the birth, said staff expressed “surprise” when Mr Ajala changed his mind on how the baby should be delivered but no one said anything. 

Mrs Hamilton-Deeley said it was the “21st century” and professionals – regardless of rank – should feel free to express their views. 
Ms Sinclair said 300 members of staff would be sent on a communication training course. 

She said while not implicated in the death, guidance not to use the ventouse on babies under 34 weeks would be reinforced. 
Discussions were still ongoing as to when was the best time to obtain consent from parents, she said.

She added it would “not be appropriate” to impose guidance on the use of forceps, which currently have no age restriction. 

Decisions would be made on a case by case basis, she said.

The trust would not confirm whether Mr Ajala, also known by the first name of Tosin, is still working at the hospital. 

Father Mike Blunden said the inquest had been “hanging over” the family’s heads since the death but they were satisfied with the conclusion, adding: “We got the answers we needed.”

After the inquest Doctor George Findlay, the chief medical officer of Brighton and Sussex University Hospitals, said: "On behalf of the new leadership team of Brighton and Sussex University Hospitals, I would like to offer my sincere condolences to Ms Witkowska, Mr Blunden and their family for their terrible loss.”