Doctor tells inquiry that baby's death could have been avoided

accident inquiry.

Dr David Lloyd, a consultant in perinatal medicine, based in Aberdeen,

said that Danielle Gilogley would have survived if she had been given

the correct mixture of air and oxygen.

He said: ''If the gas had been delivered at the same pressure, further

deterioration would have been prevented, and survival resulted.''

His comment was made during evidence on the fifth day of a fatal

accident inquiry into the death of the baby in the special baby care

unit at the Southern General Hospital.

Nursing staff had previously told the inquiry they were unaware that

the proper mixture was not being given to Danielle while she was on a

ventilator because of a pressure fault.

It emerged earlier that the medical gas supply was nearly double the

correct figure, causing the ventilator to malfunction and deliver only

air instead of pure oxygen.

Questioned by procurator-fiscal Steel Carnegie, Dr Lloyd said there

were five fatal flaws which, he believed, contributed to the death of

the infant, who had been born four weeks premature.

He said that no blood gases had been carried out on admission to the

unit, although these were instigated later. In addition, infection was

not excluded on arrival, and investigation not undertaken until much

later.

Concern was also voiced that Danielle had been bottle-fed instead of

intravenously, which was the accepted practice for babies encountering

respiratory problems.

Furthermore, he said, blood oxygen levels should have been checked,

and finally, there was a failure to administer fluid designed to stop

her lungs collapsing.

Dr Lloyd was highly critical of the lack of communication between the

Southern General's estates department, which is responsible for the gas

pressure, and the medical physics unit, which maintains equipment.

Sheriff Eric Galt heard earlier in the inquiry that the gas supply had

been set at seven bar pressure by the estates department, while

respiratory equipment operated only on four bar pressure. Neither

department was aware of the other's requirements.

Dr Lloyd said: ''What I have heard over the last four-and-a-half days

has been a chapter of failure in communication, and that is where I

think the fault is.''

The doctor cited the strict practices employed within his own

hospital's baby care and maternity unit surrounding the stringent checks

carried out, many of these on a daily or weekly basis.

There was a definite need to ensure adequate safety precautions were

adopted at all times, he continued, involving checks on both audible and

visual alarm systems.

He admitted also being ''perturbed'' that hospital staff at the

Southern General were tampering with new equipment, cutting off four bar

probes, and replacing them with the older seven bar variety.

This practice had been criticised earlier yesterday by witness Mr

Andrew Kordiak, head of the life support section within the Common

Services Agency, which acts as consultants and investigators for the

Scottish health service.

''In my opinion that practice was totally inappropriate. It is also

dangerous,'' he said.

The inquiry has been adjourned until February.