Baby’s head injuries not spotted at Stevenage’s Lister Hospital, coronor warns

PUBLISHED: 08:25 27 November 2019 | UPDATED: 08:29 27 November 2019

The coroner believes there is a risk of future deaths if action is not taken. Picture: East and North Herts NHS Trust.

The coroner believes there is a risk of future deaths if action is not taken. Picture: East and North Herts NHS Trust.


Medical staff at Stevenage’s Lister Hospital failed to spot a baby’s head injuries when she was examined a month before she died, a coroner’s report has warned.

Tillie Spencer-Adams died on June 18 last year, having been found unresponsive and with blue lips by her mother next to her in bed. An inquest concluded it had been sudden unexpected death in infancy.

The inquest heard how Tillie had been examined at Lister weeks before her death, after she was involved in a car crash on May 4.

Tillie was checked at Lister and no injuries were found, apart from a small mark on her collarbone from the seatbelt. She was discharged the same day.

Coroner Geoffrey Sullivan has sent a report to the hospital - aimed at preventing future deaths - because the post-mortem examination showed Tillie had suffered multiple head injuries and fractures to her right arm.

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Mr Sullivan said the injuries were likely to have happened as a result of the crash, adding that while these injuries "were not found to have caused or contributed to the death" the fact they appear to have been overlooked by hospital staff gave "rise to concern".

He continued: "In my opinion, there is a risk future deaths will occur unless action is taken. The deceased attended Lister following a road traffic collision in which she is likely to have suffered serious injuries which appear to have been overlooked."

But Lister says it has reviewed its care of Tillie and found it was in "line with national guidance".

A spokesman from the East and North Hertfordshire NHS Trust, which runs Lister, said: "We were extremely saddened by the death of Tillie and we note the contents of the coroner's report, noting historic injuries which were unrelated to her death.

"In May 2018, Tillie had attended the emergency department following a road traffic accident, where she was examined by senior clinicians. There was no indication of either a head or arm injury, and she did not require any pain relief.

"In response to the coroner's report, we have reviewed the care Tillie received at this time. Tillie's clinical assessment and treatment plan was in line with national guidance and we believe she was treated appropriately.

"Once again, we extend our sympathies to Tillie's family."

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