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Mother of Summer Jamsek reveals heartbreak over coroner's findings on baby's death.

By Louise Milligan.

A Melbourne mother has revealed her heartache that a Victorian Coroner has not been able to find a clear cause of death or deficiencies in care at a private maternity hospital where her newborn baby died.

A tearful Sonja Jamsek told 7.30 she was bitterly disappointed by the finding, which was released on Tuesday.

Coroner Phillip Byrne found Summer Jamsek, who was born on April 4, 2010 at Melbourne’s Frances Perry House, died with a complex condition known as pulmonary hypertension.

But he was unable to find conclusively that it was caused by an infection which should have been treated earlier by antibiotics by Summer’s paediatrician.

An autopsy did not find the presence of any infection, however, independent experts who gave evidence for the Jamsek family said that could have been because the baby was given high-grade antibiotics in the hours before her death, when she was already gravely ill.

Ms Jamsek believes Summer died because of a cascading series of delays and missed opportunities by the midwives and doctors treating her.

“She never had an opportunity to survive, because she wasn’t given the medical treatment that she deserved,” Ms Jamsek told 7.30.

“I’m grieving for the child I’ll never get to know.

“I’ll never see the first day at school, I’ll never see the wedding, I’ll never see her walk – I’ve been robbed of all of Summer’s firsts.”

‘I knew then and there … my baby was going to die’

Summer did not cry until almost seven hours after she was born. By that time she was desperately ill and doctors were working on her little body, preparing for the Newborn Emergency Transport Service (NETS) newborn ambulance team to arrive.

“The guy from NETS came out and said, ‘I just want to prepare you, your baby’s as sick as a baby can get’,” Ms Jamsek said.

“And I knew, I knew then and there, everything I had been saying was true and my baby was going to die.”

In videos tendered to the court, the midwife is heard reassuring Summer’s mother that the baby was just “a bit slow to wake up” and “it could be a little bit to do with the epidural”.

When Sonja asked her about the baby’s APGAR scores, which measure a newborn’s wellbeing, the midwife said they were seven and eight out of 10, but failed to mention that at a minute after birth, the score was five out of 10, which indicates a very unwell baby.

Ms Jamsek said the signs of problems were there right after Summer was born.

In videos taken right after her birth, the baby is seen to be blue and lethargic and her mother expressed concerns on several occasions.

“She’s just moving very slowly and her eyes aren’t really fixing on anything. Then I felt something wasn’t right,” Ms Jamsek told 7.30.

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Dr Simon Erickson, a neonatologist at Perth’s Princess Margaret hospital, said the baby appeared to be “very blue” which is a sign of a lack of oxygen.

“Often babies when they’re born, they can have blue hands and feet, and that’s normal, due to circulation, but if the baby’s face and lips are blue, then that’s a concern,” he said.

Baby Summer was making strange clicking noises.

Summer’s obstetrician said he never heard them.

A couple of hours after that, another more experienced midwife came into the birthing suite and expressed concern about Summer.

“She said, ‘this baby looks sick, get her to special care now’,” Ms Jamsek said.

That did not immediately happen. Instead, Summer was brought to the nurse’s station, where a supervising midwife also made an assessment about her colour.

“She commented that in 38 years of being a midwife, she’d never seen a baby look like that before,” Ms Jamsek said.

Ms Jamsek said the midwife “saw Summer change colour” but chose to “leave and not convey any of that information to the paediatrician”.

The inquest heard it was the paediatrician seeing Summer change colour before his eyes much later in the night that convinced him to transfer the baby to the Children’s Hospital.

The paediatrician was asked twice in an hour, by ambulance paramedics on the phone, whether Summer had been given antibiotics, but they were not administered until the paramedics arrived.

The baby was rushed to the Children’s Hospital but it was too late.

A doctor came to tell Ms Jamsek that Summer had no brain function.

“I read her a book. I read her Guess How Much I Love You? and I had her baptised and we all sang Twinkle Twinkle Little Star,” a tearful Ms Jamsek told 7.30.

“And I held her. And they turned the ventilators off. And she died in my arms.”

In a statement, Frances Perry House CEO Michael Rozek said Summer’s death was an extremely sad case and had been felt heavily by the hospital’s medical and nursing staff.

“This was a very unfortunate event and we extend our heartfelt sympathies to baby Summer’s family,” Mr Rozek said.

“Antibiotics should’ve been given earlier”

Two infant intensive care specialists told the inquest Summer may have had a chance of survival if she had been given antibiotics and she had been put on an artificial heart and lung machine hours before she was.

“I think the care wasn’t ideal. I think attention could have been given more quickly to the problems that arose,” Dr Erickson said.

He believes Summer died of pulmonary hypertension and the most likely cause was indeed sepsis, or infection.

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He and Dr Warwick Butt from Melbourne’s Royal Children’s Hospital said all other causes of pulmonary hypertension — structural lung disease, structural heart disease and severe birth asphyxia — had been ruled out so infection was all that was left.

The hospital’s experts disagreed with some of the evidence given by the two doctors, however, the hospital declined to be interviewed by 7.30.

Summer’s treating paediatrician told the inquest that at the earlier time when it’s argued he could have given her antibiotics, Summer was pink and not in respiratory distress due to being given oxygen, so he wasn’t concerned.

“Sepsis would be the most likely cause for a baby to deteriorate rapidly like Summer did,” Dr Erickson said.

He said all the signs pointed to Summer having an infection — her mother had a fever during labour and her waters had broken early and remained ruptured for more than 18 hours, Summer’s glucose levels were low and she had developed breathing difficulties in the hours after her birth.

“I’ve never heard anything like that — it was quite an eerie sound,” Dr Erickson said of the clicking sound Summer made in the video.

He said if a baby develops breathing difficulties that are not present at birth, “the diagnosis until proven otherwise should be infection”.

“Particularly with this baby, with Summer, with the history of risk of infection, I feel that the antibiotics should’ve been given earlier than they were,” he said.

Length of time taken to reach a finding criticised

The Coroner found there was an argument that antibiotics should have been given any time from 8:30pm — almost three hours before they were — and it would have been “prudent to cast the net widely”.

But because infection did not show up in Summer’s autopsy, he could not definitively rule that the failure to give the antibiotics until 11:00pm meant the baby was mismanaged.

He was therefore required to find that Summer died of natural causes.

Ms Jamsek’s solicitor Paula Shelton criticised the delay in getting the finding.

“I don’t think it is acceptable that it takes six years for a mother to get these kind of answers — it re-traumatises people, it means that they can’t move on with their lives,” Ms Shelton said.

“And very importantly, in this case the investigation didn’t take place until years after the event and what that means is that memory has faded.

“I think that had statements been taken earlier and the matter investigated earlier more definitive findings might have been positive.”

This post originally appeared on ABC News

 

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