AN OFFICIAL investigation into the death of a baby whose lungs burst after she was given 100 times more air than normal in a hospital's intensive care unit has called for a ban on equipment used to treat her.

But a report to health bosses also questions the clinical competency of one member of staff and recommends extra supervision and updated training.

The Lancashire Evening Telegraph can reveal that the nurse sacked by Burnley Health Trust over the matter was Sister Dorothy Holgate. Staff Nurse Susan Ball has been disciplined.

The nurses were caring for hours-old Colne infant Charlie Louise Taylor when an air tube was wrongly connected, causing the tragedy at Burnley General Hospital.

Now a special hospital panel, set up to investigate the incident, has called for the seldom used air equipment to be banned and removed from the neonatal unit.

It is recommending that normal ventilators are used in future and that low pressure air flow meters are used to protect babies.

In its report to Wednesday's trust meeting the panel is calling for extra supervision and updated training for all staff within the baby unit. The panel, which says there were optimum staffing levels at the unit when baby Charlie was born, wants a full review of all rarely-used equipment and a decision taken on whether to use them in future.

The panel concludes: "The clinical competency of one member of staff was clearly called into account within the panel's review and at the subsequent disciplinary hearing.

"Other issues mentioned above were considered to be peripheral rather than contributing factors towards the death of the baby."

The report, compiled by panel member Lesley Doherty, the trust's Executive Director of Nursing, reveals that when the baby suddenly deteriorated, consultant in charge Dr David Thistlethwaite was recalled, but because the apparatus had by then been disconnected, he was unaware of the cause of the lung collapse.

"It is clear that if, at that stage, either nurse was aware of the reason for the baby's sudden deterioration, then it was not disclosed to Dr Thistlethwaite.

"Furthermore there is conflict between the statements and evidence of the two nurses concerning who actually effected the connection."

The report says that it was only speculation among nursing staff following the death on January 19, 1997, that resulted in the two nurses being interviewed over the next three days. Once the facts were known the coroner and parents, Neil Taylor and Gemma Wadsworth were immediately informed.

The nurses were suspended on full pay for more than two years as police and health investigations were carried out.

The Crown Prosecution Service decided to take no action against the nurses and a Burnley inquest last year recorded a verdict of misadventure.

The incident report says that although the trust does not normally discuss or disclose details of disciplinary proceedings in public, it was already in the public domain that one of the nurses had been dismissed.

The report again expresses sympathy for baby Charlie's family and concludes: "Whilst no-one can be certain that tragic accidents will never occur again, the recommendations when fully implemented and practised, will do much to reassure public and staff that the neo-natal Intensive Care Unit provides a safe, clinically professional and sensitive environment and service for the very vulnerable babies who are cared for by a dedicated medical and nursing team."

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