Death of baby due to incorrect insertion of long line causing pericardial tamponade

We settled a claim against Portsmouth Hospital NHS Trust for the neonatal death caused by an incorrect placement of a neonatal long line which penetrated the right atrium causing cardiac tamponade.

The claimants’ son was born by emergency caesarean section in the Queen Alexandra Hospital at 28 weeks gestation. At birth, he was intubated and admitted to the Neonatal Intensive Care Unit. 

Within 24 hours, his condition had improved and he was taken off the ventilator and was breathing by himself. Within 48 hours of his delivery, a decision was made to place a long line for further care to allow for administration of fluids or medication as required. This was initially placed by a senior advanced neonatal nurse practitioner who placed the line into a vein at the knee. It subsequently transpired that the line had been inserted too far and migrated to the right atrium in the heart.  

Following the placement of the long line, the baby’s care was passed to a neonatal registrar who ordered an X-ray to check the line position. The registrar reviewed a zoomed-in image of what he thought was the position of the long line and both he and a consultant incorrectly considered that the long line was in a good position. Total parenteral (intravenous) nutrition (TPN) was then commenced through the long line. 

Within 48 hours, the baby’s condition deteriorated and he was noted to be bradycardic (low heart rate) and with no spontaneous respiration. Although attempts were made to resuscitate him, they were unsuccessful and the claimants’ son passed away soon afterwards. 

Following the death, the consultant neonatologist caring for him performed a cardiac aspiration to determine the cause of the collapse. During the aspiration, pale milky fluid was aspirated from the pericardium, in keeping with TPN fluids. It was explained to the parents that the likely cause of the collapse was pericardial tamponade (accumulation of fluid in the heart preventing its proper function) with the possibility that the long line tip was incorrectly positioned and had migrated through into the pericardium causing the TPN fluids to be pumped into the heart.  

Following the untimely death of the claimants’ son, a full investigation was undertaken  by the trust to ascertain the cause of his death and whether it could have been avoided. A number of measures were put into place to ensure that there was a continuity of care and that the person placing the long line was also the person responsible for reviewing and documenting the long line position. Given the nature of the death, the coroner was informed and a post mortem was carried out.

Subsequently an inquest was opened and a hearing held. We were instructed by the parents to represent them at the inquest and to investigate a clinical negligence claim. The causes of death given on the post mortem were: cardiac tamponade, intravenous line insertion, and prematurity.

The clinicians involved in the claimant’s care were extremely open about the failings that had occurred. A number of failings were identified and discussed at the inquest and it was clear that the trust had put in place a number of measures to ensure that similar events did not occur in the future. Following the Inquest, we served a formal letter of claim. Liability was admitted at an early stage and the defendant made an early offer to settle the case which was accepted.

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