Death of newborn at Glasgow hospital could not have been avoided, inquiry finds

Babies in neonatal intensive care units should be screened weekly for Staphylococcus aureus colonisation, a sheriff has recommended following the death of a newborn at Scotland’s largest hospital.

Sophia Smith died aged 11 days old at the Royal Hospital for Children, at the Queen Elizabeth University Hospital Campus, after contracting a toxic infection on April 11, 2017.

She became ill with an infection similar to MRSA, which developed into sepsis.

Her parents, Theresa and Matthew Smith, previously said to STV News they felt stuck in a “wasteland” in their efforts to get answers from NHS Greater Glasgow and Clyde.

A Fatal Accident Inquiry, which began in February this year, almost eight years after Sophia died, has found that no precautions could have been taken to prevent her death.

Sheriff Joanna McDonald recommended weekly screenings of babies in the neonatal intensive care unit for Staphylococcus aureus colonisation and that Public Health Scotland share risk, diagnosis and treatment information on PVL-MSSA infections, with other neonatal clinical teams throughout Scotland.

Sophia was born at the Royal Alexandra Hospital in Paisley, Renfrewshire, on March 31, 2017.

The inquiry heard that following her birth, she had difficulty breathing, as well as a possible heart issue, so she was transferred the following day to the neonatal intensive care unit (NICU) at the RHC.

There she was placed in an incubator with one-on-one nursing care and a “raft of machinery” next to her cot.

She was also given antibiotics via lines into her body, initially in her abdomen and then in her left foot.

In the early hours of April 11, she was put on a treatment involving blood being oxygenated outside the body before being returned to it.

However, by 4.45pm that day, it had become clear that Sophia was “likely to die shortly”, and it was agreed that all medical lines be removed from her body to allow her family to have time with her.

She died at 5.48pm on April 11.

Her cause of death was recorded as pulmonary haemorrhage, cardiomyopathy, Trisomy 21 (Down Syndrome) and persistent pulmonary hypertension of the newborn.

The inquiry heard blood samples taken before Sophia was admitted to NICU showed no signs of infection.

However, samples taken on April 10 and 11 tested positive for Staphylococcus aureus (SA).

The inquiry heard this common bacterium can cause serious infection if it gets into the body, such as through medical lines and catheters.

FAI findings

In her determination, Sheriff Joanna McDonald found that an active bloodstream infection caused by methicillin-sensitive Staphylococcus aureus producing Panton-Valentine Leucocidin (PVL-MSSA) contributed to Sophia’s death.

However, it was found that there were no precautions that could have been reasonably taken to prevent her death.

The PVL-MSSA infection was not related to the built hospital environment and was not associated with the new build hospital at Queen Elizabeth University Hospital campus

Procurator Fiscal Andy Shanks said: “Sophia Smith’s mother, father and their family have my deepest sympathy for all they have endured.   

“The Sheriff’s determination, which makes recommendations for NHS Greater Glasgow and Clyde and Public Health Scotland, is extensive and detailed.  

“The FAI followed a thorough and comprehensive investigation by the Procurator Fiscal, who ensured that the full facts and circumstances of Sophia’s death were presented in evidence. ”