Coroner's concern after baby girl's heart defect not detected until after death
A coroner has highlighted concerns about medical care following the death of a five-week-old baby girl.
Esme Atkinson died at Stepping Hill Hospital of a "ventricular septal defect", a hole in her heart, which was not detected until after her death.
An inquest into Esme's death heard that both her mum and her auntie had risk factors but a scan which could have detected the condition was not carried out.
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Following the inquest, Senior Coroner Alison Mutch OBE has written a prevention of future deaths report highlighting concerns around Esme's death on March 17, 2024.
The letter raises concerns with procedures within healthcare, such as at what point risk factors mean that a routine scan should be carried out.
In particular, the coroner drew attention to the fact that Esme's auntie, who is her mum's identical twin, had a heart condition, suggesting Esme was at a heightened risk.
Senior Coroner Mutch wrote: "In Esme's case although her mum's identical twin had a heart defect this did not in the North West, trigger the protocol for a routine echocardiogram. A heart defect in her mother would have."
She added: "It was unclear why this was excluded given the genetic link."
In the letter Senior Coroner Mutch also said that in order for symptoms like Esme's to be detected "training for community midwives/health visitors and GPs needed to be improved."
Drawing attention to the lack of an ECG on Esme's heart, Senior Coroner Mutch said: "There was no routine echocardiogram of a baby born of a mother with diabetes nationally although their risk of a defect was significantly higher than other babies and such a test it would detect a baby with a ventricular septal defect at an early stage."
Tragically, this test was not carried out and just a five weeks after welcoming their baby daughter Esme's parents Ellen Roberts and Louis Atkinson were left grieving her loss.
In a joint statement shared with the Manchester Evening News, they said: 'From the moment we found out we were expecting, Esme was so loved and we couldn't wait to welcome her into the world.
'Not for one minute did we expect to lose her so suddenly after just five weeks. Having to say goodbye was the hardest thing, and to this day the pain and grief still feel as raw now as back then."
They added: 'There's not a day goes by when we don't miss Esme and we'll continue to honour our baby girl's memory however we can.'
The coroner directed her concern to the Secretary of State for Health and Social Care and Greater Manchester NHS Foundation Trust, and a copy of the coroner's report was sent to Esme's mum Ellen Roberts, as well as Stepping Hill Hospital and the Chief Coroner.
A Department of Health and Social Care spokesperson said: 'This is a tragic incident and our deepest sympathies are with Esme's family.
'We are committed to learning lessons from every prevention of future deaths report and will consider the findings carefully before responding formally."
The Manchester Evening News has approached NHS Greater Manchester Integrated Care Board for comment.
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