A higher dose of medicine might have saved baby Amir. Hospital staff didn’t want to ‘waste’ another vial

Amir was just two days old when he died at the Royal Women’s Hospital from respiratory distress syndrome. The recommended dose of medicine might have saved him.

Baby Amir was just two days old when he died from respiratory distress syndrome.

A newborn who died after receiving a lower-than-recommended dose of medicine may have been saved if the hospital had acted quicker, a Coroner has found.

Amir was just two days old when he died at the Royal Women’s Hospital from respiratory distress syndrome, pneumonia and a collapsed lung in August 2020.

But a Coroner’s Court has now found earlier RDS treatment may have saved him and heard staff – to avoid opening and “wasting” another vial – gave him a lower dose than hospital guidelines recommend.

Coroner Dimitra Dubrow said while it was “not possible” to rule the correct diagnosis and treatment would have definitely saved Amir, it may have.

A coroner has found Amir may have survived had the hospital given him the recommended dose. Picture: David Crosling

“Such treatment including earlier administration of dose appropriate surfactant and repeat doses may have reversed Amir’s deteriorating condition and prevented his ultimate death,” she said.

The findings, released last month, come after the hospital spent years defending his care, which their internal reviews said matched “best practice”.

RDS occurs when babies’ lungs are missing an important molecule, surfactant, that helps them breathe, and can be treated in most cases by one or two doses of an artificial version.

The Coroner heard Amir was in good condition until about 11 hours after birth, when his mother called for help and Amir, whose skin was blue, was resuscitated.

The Royal Women's Hospital has spent years defending its care of Amir. Picture: iStock

He was transferred to the NICU, diagnosed with collapsed lungs and mild pulmonary hypertension — but not RDS — and died two days later on August 12.

The RWH never reported his death to the health department body, Safer Care Victoria, because the hospital did not consider it a “serious” adverse event.

But Coroner Dubrow identified three key issues, including a delay in recognising and responding to an “abnormal” blood test done more than 90 minutes before he deteriorated.

She found the underlying cause of Amir’s collapsed lungs required “further investigation” but features “suggestive” of RDS were “not appreciated”.

And when Amir was given surfactant, almost an entire day after he first deteriorated, the dose was below the hospital’s guidelines.

The RWH said this was “influenced by considerations of wasted vials”, “likely” because “20 per cent of a further vial would have been used to achieve the prescribed dose resulting in waste of the remainder”.

But Coroner Dubrow found the hospital’s prescribed doses, if followed, were still “below those of the manufacturer, and other interstate and international guidelines”.

Royal Brisbane and Women’s Hospital consultant neonatologist Dr Janet Sharpe, asked to review the case, said the RWH’s guidelines to reduce dosages “purely as a means to ‘minimise waste’ (and hence cost)” were “not consistent with the latest available evidence”.

The hospital never reported Amir’s death to Safer Care Victoria, despite it being legally required to do so. Picture: David Crosling

The RWH guidelines match SCV’s and the state’s specialist service for critical infants’ transport, prompting the Coroner to urge all three to review them.

She also recommended newborn parents be informed, including via visual aids, to notify carers about any changes in breathing or colour.

The Coroner heard his mother later told staff she was concerned about the colour of Amir’s lips and legs about an before he collapsed.

She said a midwife came in and said she would be back in a minute, but did not return, while his medical records state a midwife, who flagged she was going on a break, observed Amir as “alert and pink in colour” at 2.45pm.

The Coroner heard Amir’s case was complex because his presentation was “not usual”, RDS is rare in full-term babies and some of his symptoms were mis-attributed to his collapsed lungs or hypertension.

RWH Safety and Quality director Catherine Jones submitted their internal reviews into Amir’s case were “in-depth” and, it was rated as a less serious incident, because “there were no contributing factors identified”.

“In cases like these, the lessons are derived from what we did right, rather than what went wrong,” she said.

The hospital's safety and quality director said lessons would be derived from 'what we did right, rather than what went wrong'. Picture: iStock

The hospital “acknowledged” late last year – after Dr Sharpe’s evidence – the “abnormal” blood test but disputed other claims, and said RDS features were not “obviously present” in the initial X-rays.

They defended their surfactant guidelines, and said they usually related to preterm babies, whereas Amir was full-term and they did not consider his dose insufficient.

“There are no evidence-based recommendations for surfactant use in term infants with RDS,” they said.

A RWH spokeswoman told the Herald Sun they were “deeply saddened” by Amir’s death and the “pain and suffering experienced by his parents”.

“The loss of a baby is heartbreaking,” she said.

“The neonatal environment is challenging, and each baby has their own complexities.”

The spokeswoman said their reviews and guidelines were “robust”, they “always” strive to “provide the best possible care” and “accept” the Coroner’s findings.

But neither she, nor SCV, directly answered when asked if they had begun a review of surfactant guidelines.

An SCV spokeswoman said they would “work closely with the sector to review the guidelines”.

When asked if they were confident all other adverse cases had been reported to SCV given Amir’s was not, the spokeswoman said hospitals must report all cases.

Originally published as A higher dose of medicine might have saved baby Amir. Hospital staff didn’t want to ‘waste’ another vial