The recent inquest into the deaths of two premature babies, Elena Ali and Sunny Parker-Propst, at Chelsea and Westminster Hospital highlights the critical importance of the need for rigorous checks in neonatal care. The findings from this case, alongside insights from recent NHS maternity reviews, underline the urgent need for systemic changes to prevent such tragedies from occurring.

In April and May 2020, two families faced unthinkable losses when their newborn babies died due to a prescribing error of medication in the neonatal intensive care unit (NICU) at Chelsea and Westminster Hospital. Both babies were prescribed sodium bicarbonate infusions to treat metabolic acidosis but were given sodium nitrite in error instead. This fatal error led to the deaths of Elena Ali and Sunny Parker-Propst, just 12 days apart from each other.

Elena and Sunny's inquest occurred at Westminster Coroners' Court between 8 and 22 July 2024.

After a 10-day inquest, conclusions of unlawful killing contributed to by neglect for Sunny and accidental death contributed to by neglect for Elena were found by the jury. These verdicts highlight severe lapses in care by the hospital's pharmacy and nursing staff.

The coroner revealed that the hospital's chief pharmacist admitted to a "complete and total" failure in the pharmacy's checking procedures. At the inquest, it was disclosed that the pharmacy could not identify the person who issued the wrong drug.

The inquest heard how the NICU's neonatal nurse coordinator had failed to follow a policy to check medication vials by picking them up and looking at them at eye level to check the medication. She accepted that if she had followed this procedure, she would have been able to see that the drug was, in fact, sodium nitrate, not sodium bicarbonate.

The Chelsea and Westminster Hospital NHS Foundation Trust chief executive, Lesley Watts, said on behalf of the Trust: "We apologise unreservedly for the failings in care provided to Elena and Sunny." She added: "We took immediate action to put measures in place to prevent such tragic incidents from happening again."

NHS Maternity and Neonatal Programme

In March 2023, NHS England agreed to the Three-Year Delivery Plan for Maternity and Neonatal Services. The plan aims to support women and families and improve care.

"The four themes of the plan are:

• Listening to and working with women and families with compassion
• Growing, retaining, and supporting our workforce
• Developing a culture of safety, learning and support
• Standards and structures that underpin safer, more personalised, and more equitable care."

NHS England published an update from their Maternity and Neonatal Programme in October 2023 that states, "Making sustainable improvements across maternity and neonatal services remains a major priority for NHS. We are strengthening the services delivered further through targeted investment, leadership, and support for quality and safety improvement. However, maternity and neonatal services face significant challenges. While we have made good progress, and there are encouraging signs, sustainable improvement will take time and require ongoing focus and investment."

Recent audits, reports and recommendations

MBRRACE-UK

The latest MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) Perinatal Mortality Surveillance Report found that the proportion of trusts with maternity services "red rated" for neonatal mortality rose from around a quarter in 2021 to a third in 2022.

MBRRACE classifies trusts from red to green according to how far above or below their peer group providers they are. Green refers to areas where improvements or progress is being made, and red refers to critical issues requiring improvement.

Out of 121 trusts, 41 (34%) were rated "red" for neonatal mortality in 2022, as their rates were over 5% higher than their peer group average. This compares with 32 trusts (26% of 123 trusts) rated "red" for neonatal mortality in 2021.

There have also been areas of improvement year on year. The number of trusts rated "green"—with neonatal death rates more than 15% lower than the average in their peer group—increased from three in 2021 to eight in 2022, marking a significant improvement from 2020 and 2021.

National Neonatal Audit Programme

The National Neonatal Audit Programme (NNAP) provides recommendations for improving neonatal care based on their audits and reports. Some of their key recommendations that link to this case are:

Ensure Adequate Staffing Levels :

• Recommendation: Ensure neonatal units are staffed according to the British Association of Perinatal Medicine (BAPM) guidelines to provide safe and effective care.
• Rationale: Adequate staffing is crucial to meet the needs of all infants, particularly those in critical condition.

Implement and Adhere to Protocols :

• Recommendation: Follow established clinical guidelines and protocols for caring for premature and sick neonates, including those related to resuscitation, infection control, and temperature management.
• Rationale: Adherence to evidence-based protocols helps standardise care and reduce variability, which can improve outcomes.

Regular Training and Development :

• Recommendation: Provide ongoing training and professional development opportunities for all staff involved in neonatal care to ensure they are up-to-date with the latest practices and technologies.
• Rationale: Continuous education helps maintain high standards of care and adapts to advances in neonatal medicine.

Enhanced Communication Channels :

• Recommendation: Develop robust communication strategies to ensure effective information exchange among multidisciplinary teams and between healthcare providers and families.
• Rationale: Clear and effective communication is essential for coordinated care and reducing errors.

The deaths of Elena Ali and Sunny Parker-Propst are tragic reminders of the importance of diligence, proper training, and adherence to safety protocols in neonatal care. They should serve as a catalyst for meaningful change within the NHS.

As clinical negligence solicitors, it is our hope that the NHS can eradicate such preventable errors by learning from these tragic cases and utilising the findings of reviews into maternity and neonatal care.

If you or someone you know has been affected by similar issues, seeking legal advice can help you navigate these difficult circumstances. At Switalskis, we are committed to supporting families through every step of their journey to justice and closure.

Contact our specialist birth injury solicitors

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