Baby died at Royal Sussex, Brighton, after mum had allergic reaction

Dio Brummitt-Shemain was born on July 24, 2022, by emergency C-section at Pembury Hospital in Tunbridge Wells after his mum had anaphylaxis, a life-threatening allergic reaction to the drug syntocinon.

That evening he was transferred to the neonatal unit at the Royal Sussex County Hospital in Brighton where he later died.

Dr Rephainah Mallett, an obstetric and gynaecology registrar, had decided to give mum Emma Shemain the drug in the labour ward at Pembury Hospital 12 hours after her waters broke.

In an inquest into Dio’s death held at Woodvale Coroner’s Court in Brighton yesterday, Dr Mallett told the court the drug syntocinon, a synthetic form of oxytocin, is used to increase the frequency and strength of contractions.

Pembury Hospital in Tunbridge Wells (Image: N Chadwick)

Emma, who lives in Edenbridge, near East Grinstead, was given the drug by a hormone drip.

Dr Mallett said: “We explain the risks of syntocinon to patients.

“We start with a very low dose and slowly increase it depending on how the baby is dealing with contractions.

“If there is any concern with the baby’s toleration of contractions we will reduce the level of syntocinon given.”

At 3.30pm a midwife started Emma’s syntocinon drip.

By 4.40pm, an emergency buzzer was called in the hospital. Baby Dio’s heart rate was low and Emma’s lips and tongue were swollen.

Dr Mohammad Akhtar, an obstetric anaesthetist who has worked at Maidstone and Tunbridge Wells NHS Trust (MTW) for 20 years, was bleeped to Emma’s hospital room.

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At the inquest on Wednesday, May 1, Dr Akhtar said: “I went there immediately and noticed there were a few people there.

“Emma was breathing very fast, her lips and tongue were very swollen. She was having an allergic reaction to a drug.

 “Any drug can cause anaphylaxis but I haven’t never come across anybody who has ever reacted to syntocinon like this

“It couldn’t have been prevented or foreseen.”

Emma was then transferred to the operating theatre to have a C-section and was given hydrocortisone, which at the time was part of anaphylaxis packs at the hospital.

A few minutes later she was given adrenaline.

“Within a few minutes her breathing was much better,” Dr Akhtar said.

Asked by coroner Dr Karen Henderson whether the outcome would have been different if Emma had been given adrenaline sooner, Dr George Graham, a consultant anaesthetist at MTW said: “I think it is possible that the time it took to give adrenaline had an effect.

“Adrenaline is the treatment of choice and should be administered as soon as possible.”

Emma’s clinicians had planned to induce her because she was 41 years old when she was pregnant with Dio and the older mothers, especially those over 40, are the more likely they are to have stillbirths.

Mr Alex Slack, consultant gynaecologist and obstetrician, at MTW told the court other risks to Dio were that Emma’s second baby was smaller than average and Dio’s growth had slowed between his 37 and 39-week scans.

Once Emma was no longer in anaphylaxis, she was given a spinal anaesthetic so surgeons could carry out the C-section.

She could not be given general anaesthetic as it is administered by breathing through a mask and due to her anaphylaxis she could not do that.

Dr Akhtar said: “If I was unable to oxygenate Emma it would put her at huge risk.”

By 5.18pm, Dio had been born by an emergency C-section.

Because Emma had anaphylaxis, her blood pressure was reduced meaning the flow of oxygenated blood to her placenta was also reduced.

It caused Dio to have hypoxic-ischemic encephalopathy, a type of brain damage caused by lack of oxygen before birth.

Dio was resuscitated before being transferred to the Royal Sussex County Hospital.

Despite treatment, Dio was not going to survive and was taken off intensive care on July 30.

He died in his parents' arms in the early hours of July 31.

Allergy tests later revealed Emma, a beauty therapist, has a very rare allergy to syntocinon.

Concluding the inquest, assistant coroner for West Sussex, Brighton and Hove, Dr Henderson said: “Dio was a much beloved and cherished son of Emma Shemain and Bobby Brummitt.

“I have no doubt the pain of his loss from the immediate family ripples out to the wider community.

“I accept that the anaphylaxis could not have been foreseen.

“This is something so rare that all the doctors have never seen it in all their practice

“No steps could have been taken to have prevented these complications.

“Dio was sadly born in a very poor condition.

“Dio’s death was due to complications arising from foetal compromise due to severe and prolonged bradycardia as a result of maternal anaphylaxis.”