March 9, 2023 | Mark Paradies

Baby Dies After Misdiagnosis

East Surry Hospital

Surry News Reports Tragic Death at East Surry Hospital

A two-month-old baby died of NEC (necrotizing enterocolitis) when a hospital failed to spot warning signs and didn’t follow up with a barium enema. A post-mortem examination confirmed this.

The mother said:

“Trying to come to terms with what happened is something I don’t think
we’ll both ever get over. When we lost Nailah our lives changed forever.”

The Surry news reported that the hospital’s root cause analysis:

“…found there was a failure to perform a barium enema, which in retrospect, may have found Nailah’s narrowed intestine which she suffered ‘due to her episode of necrotizing enterocolitis.'”

“The report also found there was a “missed opportunity” to recognize how sick Nailah was when she attended the hospital on January 10.”

What Do You Think

The items the press reported from the root cause analysis sound much more like Causal Factors than root causes.

Were the root causes identified, and will effective corrective actions be implemented?

If the NHS is performing effective root cause analysis, why are similar events continuing year after year?

Patient Safety & Healthcare
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