Baby concerns were ignored - inquiry into little Luca’s death led to junior doctor crisis at Bedford Hospital

Luca Downie.
Luca Downie.

Bedford Hospital has apologised to the mother of a 10-month-old boy who died from a rare heart disease after her concerns about his worsening health were ignored.

At the inquest into the death of little Luca Downie, his mother Lisa Fregapane described how doctors failed to take her requests they looked into a heart murmur seriously despite repeatedly taking him to the hospital with breathing difficulties.

An internal investigation into his eventual death sparked the crises which saw junior doctors removed from the hospital’s paediatric unit and the suspension of paediatric A&E last July.

Bedfordshire and Luton Senior Coroner Thomas Osbourne heard how the heart murmur was noted during the first few hours after his birth at the hospital, on June 12, 2012. On four separate occasions at the hospital, a heart murmur was detected but no action was taken.

He also heard how poor communication between Bedford Hospital over a referral request to Great Ormond Street Hospital contributed to a lack of diagnosis and any palliative care.

In her statement read to the court Miss Fregapane described how she repeatedly took him to Bedford Hospital with serious breathing difficulties and requested echo-cardiagram tests but was ‘fobbed off’, with one consultant telling her Luca wasn’t ill.

She said: “I felt like I was constantly battling with hospital staff to be listened to.”

In January, 2013, an echo-cardiagram was taken and a letter was written to Great Ormond Street Hospital referring Luca to a specialist. But due to a system failure, that letter was not read until March 13.

In the meantime, Miss Fregapane, had taken her son back to the hospital to chase up the appointment.

On April 11, she took him again after he began to struggle to breathe and turned blue. On this occasion, a chest x-ray and repeat echo cardiogram was urgently requested by the doctor who examined him, but to Miss Fregapane’s surprise, he was discharged the next day with neither test being carried out despite her voicing deep concerns.

He was re-admitted on April 14, where there was a delay in dealing with him, and poor communication with Great Ormand Street Hospital which prevented him being transferred before he died just before 8pm.

During the inquest the coroner heard evidence from nurses and junior doctors saying they felt they were not adequately supported by senior staff on the paediatric ward.

The hospital’s former medical director Edmund Neale, who was in charge at the time of Luca’s death, said it was as a direct result of the failings in the paediatric department highlighted by the subsequent internal inquiry, an action plan was implemented to improve the service.

He described a detailed list of recommendations the hospital has since implemented in the department, and across other wards, which has led to the reinstatement of trainees, due to start next month.

He added: “I would like to say on behalf of Bedford hospital we are very sorry and deeply regret that we were unable to make Luca’s final weeks and months better.”

The post mortem examination revealed Luca had an extremely rare heart condition which caused a narrowing of the coronary arteries, and while a diagnosis may not have changed the outcome, it could have led to him receiving palliative care.

Mr Osbourne returned a narrative verdict.

He said: “Throughout Luca’s life there was a failure to recognise the serious nature of his illness that resulted in a number of lost opportunities to render medical treatment.

“He died at Bedford Hospital at 19.55 on April 14, 2013, from a rare heart abnormaility – suprarvalvar Aortic Stenosis – that is unlikely to have been treatable.”

He added, Miss Fregapani might find some comfort that as a direct result of her experience and Luca’s short life, the paediatric unit has “improved beyond recognition”.