Antoniades v East Sussex Hospitals NHS Trust

In neonatal resuscitation, the standard of care requires trained clinicians to follow the established sequence of securing the airway before progressing to breathing, circulation and drugs. Where ventilation fails and the evidence indicates airway obstruction, the clinician must address the obstruction promptly, even if its precise cause is unusual. Continuing ineffective CPR and drug administration while the airway remains obstructed is not justified merely because other practitioners might act similarly in an emergency. The standard is that of the reasonably competent practitioner in the relevant position, allowing for the circumstances but applying the benefit of appropriate training. A failure to communicate known obstruction and a failure by the responsible paediatrician to ensure effective airway management may constitute negligence where timely intervention would have avoided the injury.

The claimant was born at Eastbourne District General Hospital in poor condition and suffered profound hypoxic-ischaemic brain injury shortly after birth. His airway was obstructed by a thick mucus plug. Several clinicians attempted intubation, ventilation, narrow-bore suctioning, CPR and drug administration. Effective ventilation was achieved only when a consultant anaesthetist used direct suction through the endotracheal tube.

The claim alleged negligent neonatal resuscitation during the period before irreversible brain damage occurred. The principal issues were whether the clinicians had recognised or should have recognised the airway obstruction, whether they acted in accordance with the standard practice expected of reasonably competent practitioners, and whether any breach caused the claimant’s brain damage.

1. Liability. Judgment was entered for the claimant on liability, with damages to be assessed.
2. Applicable standard. The Newborn Life Support material represented the standard practice for neonatal resuscitation. The relevant sequence was the A-B-C-D algorithm: airway, breathing, circulation and drugs. Establishing a patent airway was the essential first step. CPR and drugs could not usefully oxygenate the child while the airway remained obstructed.
3. Recognition of obstruction. Although obstruction by a mucus plug in a newborn was rare, the fact of obstruction should have become apparent by about 1922, or at the latest when repeated narrow-bore suctioning failed. The unusual nature of the material did not excuse failure to address the evident airway problem. The differential possibilities had been substantially eliminated, while ventilation remained absent or inadequate.
4. Dr Debuse. The junior anaesthetic registrar acted with the skill and care appropriate to her position and experience. She was not given the support and specific airway-management advice which she needed.
5. Dr Elmusa. He was negligent in failing to report that the first endotracheal tube had been blocked with secretions and in failing to tell the other clinicians, after narrow-bore suctioning had failed, about direct suction through the tube. The latter omission deprived the team of a timely opportunity to clear the obstruction and caused the irreversible injury.
6. Dr Ahmed. The paediatric consultant was negligent in failing to maintain focus on the airway, failing to provide appropriate direction to the clinician managing it, and permitting attention to be diverted to ineffective activity concerning breathing, circulation and drugs. Had direct suctioning been administered before 1930, the claimant would probably have avoided irreversible brain damage.
7. The failure to inform Mr Rochester of the airway problem occurred too late to cause the damage, although it illustrated the earlier loss of focus on the airway.