A rescheduled inquest opening 29 January 2020 at The Coroner's Court, Beacon House, Whitehouse Road, Ipswich, may finally get to the truth as to why one-day old Riyad Ali died on 16 July 2005 at Ipswich Hospital.
Originally anticipated to be held in July 2019, the inquest was delayed so that one of the independent experts, initially asked to prepare an additional report, could attend and give that evidence in person.
Problems with the birth
Riyad was born by normal vaginal delivery, however his Apgar score (the test used to check a baby's health) was poor and he was taken to resuscitation. His mother, Bilkis Ali, visited her new-born son over the course of the next 24 hours and was consistently provided with reassurance. At 5:00 pm the following day, when Mrs Ali went to visit her son, she was told that they were “working on him” and was sent to a side room - she had no idea of the seriousness of his condition. In fact, Riyad was very sick and medical staff were now doing all they could to save him. Cardiac massage commenced but resuscitation was discontinued at 5:25 pm and Riyad’s ventilator was turned off 20 minutes later.
Couple told that ‘genetic factors’ were cause of death
Mrs Ali was advised by doctors at the time that ‘genetic factors’ were the likely cause of her son’s death and it was implied that a post-mortem was not necessary. She accepted what the medical professionals had told her, believing that the cause of Riyad’s death was indeed due to hereditary issues. Inevitably, the feeling that somehow the very make-up of she and her husband had in some way been the inadvertent cause of their son’s death had a terrible psychological and emotional impact on the couple.
Later, as part of her ante-natal care prior to the birth of her third child, Mrs Ali was asked to provide information about her previous pregnancies. Her midwife suggested that she request her medical files in relation to Riyad’s birth. It was only then she discovered that the official record and notes were at odds with what she had been told at the time of Riyad’s death.
Hospital did not consult family during investigation
Mrs Ali further discovered that there had been an investigation - a Serious Untoward Incident (SUI) report - into the cause of her son’s death, about which she had not been informed, nor had the hospital ever consulted her. From the information in those records it was clear that there were significant failings in the care provided and several missed opportunities for a pediatrician to be consulted when Riyad’s poor condition was obvious.
This led Mrs Ali to approach the Coroner and request that an inquest be opened. The Coroner obtained a report from a neonatologist and concluded that this evidence was sufficient for him to agree to open an inquest. Given that Mrs Ali had been told that Riyad’s death was due to hereditary factors, the Coroner also ordered genetic tests on Riyad’s retained cells and DNA from both parents. Shoosmiths understands that those tests could not identify any known genetic changes that would explain why Riyad became so unwell after birth.
Representation at inquest
The family is represented at inquest by Shoosmiths’ appointed counsel, Christopher Johnson, from Doughty Chambers and Natalie Blunden, a paralegal in Shoosmiths’ medical negligence team. Sue Prior, a senior associate in the same team, is dealing with the family’s case and potential civil claim. Sue commented:
‘The duty of candour has been enshrined in law since 2014 for NHS bodies, so the fact that the family were not consulted or even made aware of the serious untoward incident investigation or its conclusions is deeply troubling. Being left to believe the only possible cause of their baby’s death was genetic or metabolic issues, for which they have blamed themselves, has also taken a toll on Bilkis and her husband. Their hope is that a full inquest will give them clarity about what really may have caused their son’s tragic and perhaps avoidable death.’