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A newborn baby who died after contracting a serious infection would have survived if he had been given antibiotics hours earlier, a coroner has ruled.
An inquest into the death of Archie Powell was told doctors missed chances to prescribe the medication, and even after recognising he had sepsis failed to administer the drugs for more than three hours.
The failures left him with a significant brain injury, which he didn't survive.
The tragedy is the latest preventable baby death at sites run by East Kent Hospitals, which is currently subject to an independent investigation into its maternity services.
The inquest today was told Archie was born with his twin sister at the QEQM hospital in Margate in February 2019.
He started grunting, had a low temperature and was not feeding well after his birth in the early hours.
But despite concerns raised by midwives just after 7am, he was not medically assessed by a paediatrician until 9.25am, at which point he had stopped grunting and so was simply kept under observation.
During an inquest at County Hall in Maidstone, it was heard however that he started grunting again at 10.50am and had become hyperthermic, yet another a delay occurred, this time in admitting him to the special care baby unit (SCBU).
He eventually arrived at SCBU at 12.45pm with "significant respiratory difficulty", and the registrar recognised Archie had sepsis and needed antibiotics, but it wasn't until three hours later - at 3.50pm - they were administered.
Assistant coroner Catherine Wood said had he been given antibiotics before midday, he would have survived.
She said by the time he received the antibiotics it was too late and he died from severe brain damage on February 14, after being transferred to the Evelina Hospital in London, leaving parents Dawn and Kevin Powell, from Margate, heartbroken.
'Had Archie been prescribed and administered antibiotics earlier, he would not have died'
Ms Wood said: "Antibiotics were given too late and sadly by that stage the dye had already been cast for Archie. It was too late to make a difference.
"When he arrived at the Evelina he was very unwell and it was difficult to assess and treat him. He was treated, but unfortunately despite all of the care, there was evidence that he had significant brain injury and was unlikely to survive."
Ms Wood said there were missed opportunities to administer antibiotics intravenously, failures to properly communicate Archie's condition and failure to escalate the situation.
She confirmed that Archie had died from sepsis caused by common bacterial infection group B streptococcus, picked up congentitally during labour from his mother.
The bacteria is commonly found in pregnant women and in rare cases can spread to the baby, making them unwell. However, it is not routinely tested for.
Giving her conclusion, Ms Wood said: "I accept the failures in this case had significant consequences for Archie, but I do not consider they were sufficient to amount to neglect.
"Archie died as a consequence of congenitally acquired group B streptoccocus and he developed signs of respiratory distress, a sign of infection in neonates.
"There were missed opportunities to prescribe him antibiotics that morning and had he been prescribed and administered them before midday, he would not have died."
Sarah Shingler, chief nursing officer for East Kent Hospitals. which is responsible for the QEQM hospital, apologised on behalf of the trust for his death.
"We recognise that we could and should have done things differently for Archie and we apologise unreservedly for failing him and his family," she said.
"Since Archie’s death in 2019, we have made a number of changes within the service to clinical practice and to staff training.
"We fully accept the coroner’s findings and conclusion and we will continue to implement changes as part of our ongoing work to make long-lasting improvements in our service.
"Archie’s tragic death shows how important this work is, and we will continue to strive to make sure that every family we care for can be confident that they will receive a consistent, high-standard of care."