New rules on baby care after deaths inquiry

Doctors have been told to stop using an intravenous feeding technique on sick premature babies after an inquiry into the deaths of four children at hospitals in Greater Manchester.

The babies – between two days and one week old – died in intensive care units of a rare complication, after tiny plastic feeding tubes were inserted into their hearts. The technique has been used on up to 1,600 newborn infants annually.

Yesterday, the chief medical officer, Professor Liam Donaldson, issued guidelines modifying the way that severely sick babies are intravenously fed. Doctors will in future be expected to adopt an alternative, but still risky, method of inserting the tube into a large vein near the heart. The medical profession was divided over the advisability of inserting tubes into the heart itself, and Professor Donaldson said no blame should be attached to doctors who had carried out the procedures.

Adopting a "shame and blame" culture in the NHS would not help to improve NHS services, and he hoped the error would be a "source of learning, not judgement", he said.

The intravenous feeding technique is used only on gravely ill babies born with complications that prevent them feeding normally. A tiny plastic catheter is inserted into a vein in the neck, or elsewhere in the baby's body, and pushed towards the heart so liquid nutrients can be added to the bloodstream.

Doctors have been divided over whether it was safer to place the tip of the catheter inside one of the chambers of the heart, or just outside in the vena cava, a large vein. The nutrients must be released in or close to the heart, where there is a good blood supply to disperse it around the body.

In the four cases, the position of the catheter head in the heart caused irritation and a leakage of fluid, which in turn put pressure on the heart, causing it to fail.

Dr David Hallworth, a consultant anaesthetist at the Royal Hospital for Sick Children in Glasgow, helped to carry out the review and said that both procedures were risky.

Some doctors held that when children were gravely ill the risk of inserting directly into the heart was justified, because the nutrient would be properly diluted in the bloodstream. "All these babies required this. An insertion of the line was fully justified," he said.

Cardiac tamponade, the complication that caused the deaths, was extremely rare. None of the doctors had seen it before, and Dr Hallworth estimated that a doctor would only experience a case once in 20 years.

Dr Unni Wariyar, a consultant paediatrician at the Royal Victoria Infirmary, Newcastle, said the hearts of newborn babies were only the size of a walnut, and it was extremely difficult to position the tip of the tube in exactly the right place. It was possible for the tube to move and puncture the heart.

The four cases were all uncovered in Manchester after an inquest last year on four-day-old Connor Highton, from Shaw, near Oldham. The baby suffered from low blood sugar, and a catheter was inserted to feed him, but he died in Royal Oldham Hospital.

Recording a verdict of death by misadventure, the coroner, Barrie Williams, called for extra safeguards on intravenous feeding. Three other cases came to light in the same area which had occurred over the previous two years. Six-day-old James Ashworth had died at St Marys Hospital, Manchester, the same month. Ten-day-old Daniel Carpenter, who weighed only a little over 2lb, died at Stepping Hill Hospital in Stockport after a catheter was inserted in his heart. Another baby, named Katie, died after seven days of cardiac tamponade, also at St Marys Hospital.

Professor Donaldson said research was continuing to establish whether similar deaths had occurred elsewhere in the country. He added that many of the gravely ill babies in intensive care would not survive without intravenous feeding.

"The field of care reviewed in this report is at the leading edge of complex high technology medicine. Many of the 12,000 sick babies treated in intensive care each year are quite literally clinging to life. This presents new evidence we have not seen before and points the way to making a rare complication even rarer," he said.