Esme Atkinson

1. 1. delayed detection of congenital heart defect

   “The inquest heard evidence that health visitors /midwives and GPs play a key role in the early identification of a heart defect such as [the deceased]'s at an early stage. Such a defect will rarely be apparent at the 72 hour check on the evidence given at the inquest but symptoms will manifest subsequently. Such symptoms can be subtle and the inquest was told that for there to be early suspicion, of a heart defect, training for community midwives/health visitors and GPs needed to be improved and good quality information sharing was also essential. This should include concerns around feeding and weight loss.”

2. 2. missed opportunity for congenital heart defect detection at 6-8 week GP visit

   “The GP check at 6- 8 weeks was a key checking point but needed to be informed by asking all of the right questions and a good understanding of how to listen for such a heart defect.”

3. 3. inadequate risk assessment for infants of diabetic mothers

   “The inquest was told that it was important that it was understood by health professionals involved in the care of a baby that the mother being diabetic increased the risk of a defect significantly and should increase the care taken in relation to presenting symptoms.”

4. 4. absence of national protocol for routine echocardiography in infants of diabetic mothers

   “There was no routine echocardiogram of a baby born of a mother with diabetes nationally although their risk of a defect was significantly higher than other babies and such a test it would detect a baby with a ventricular septal defect at an early stage”

5. 5. failure to apply genetic risk protocol for family history of congenital heart defect

   “In [the deceased]'s case although her mum's identical twin had a heart defect this did not in the North West, trigger the protocol for a routine echocardiogram. A heart defect in her mother would have. It was unclear why this was excluded given the genetic link.”

6. 6. delayed recognition of feeding and weight issues as warning signs

   “The evidence of the paediatricians at the inquest was that tracking weight on the centile chart even from an early point assisted in understanding if there was a significant issue in relation to feeding triggering professional curiosity. However the evidence from the Health Visitor appeared to suggest that centile tracking was not seen as useful before 1 month and the red book was not used to look at weight centile tracking in the early stages.”

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