One of UK's smallest ever babies who fit in sandwich bag died after 'call handler's mistake'

One of the UK's smallest babies who could fit in a sandwich bag tragically died after a call handler failed to put her as high priority when she suddenly dropped ill, an inquest has heard.

Robyn Chambers, from Wales, was born at a mere 23 weeks gestation and weighed just 11oz on March 8, 2023. After receiving round the clock care, she was finally discharged 18 months later. Her parents, Chantelle and Daniel said their daughter was "thriving" at home.

However, weeks later, the little girl took a turn for the worse and her parents noticed that something wasn't right. Chantelle alerted the emergency services, but a call handler wrongly downgraded their priority to an amber two call - meaning serious but not life threatening.

The baby had suffered hypoxic brain injury from birth and required a lot of oxygen therapy. On this particular day, Chantelle had noticed her oxygen saturation levels were low.

READ MORE: Miracle premature baby born at just 22 weeks saved by medic using sandwich bag

Chantelle told the inquest: “It wasn’t unusual for her to struggle for oxygen but on this particular day her oxygen saturation levels were much lower than usual. We did everything we’d usually do in that scenario. We performed oral and nasal suction, we increased her oxygen intake, we used a nebuliser, and gave her jaw thrusts.

“Her condition didn’t improve and we decided to ring the ambulance. The ambulance call handler said it wasn’t an emergency and an ambulance wouldn’t be sent. I phoned the Grange (hospital) myself and explained the situation and Robyn’s medical history and they said they needed to see her straight away.”

Senior coroner Caroline Saunders confirmed to the inquest that Chantelle had told the call handler that her baby would die without fast medical attention from a clinician due to her saturation levels being so low. But the call wasn’t reprioritised. Although the coroner did conclude that it was unlikely Robyn would have survived even had the call received the highest priority red status, reports Wales Online.

Chantelle and Daniel decided to do their best to rush Robyn, attached to her excessive and heavy breathing apparatus, to A&E themselves which was very tricky in a car on her dad’s lap in the passenger seat. Chantelle explained: “It was almost impossible to carry Robyn in the car with all of her equipment attached to her as well as the oxygen cylinder. She wasn’t in a fit state to be in a car seat. She stayed on her dad’s lap while I drove to the hospital which felt extremely dangerous but we had no other choice.”

Despite the best efforts of medics at the Grange and the University Hospital of Wales where she was later transferred Robyn couldn’t be saved and became completely reliant on respiratory support. After her lung collapsed and she showed no signs of being able to breathe alone for an extended period of time Chantelle and Daniel agreed with medical professionals it was best to allow their daughter to pass away as peacefully as possible at Ty Hafan Children’s Hospice in Sully on November 2 last year.

Robyn’s inquest at Newport Coroners’ Court heard her parents were, albeit unofficially, experts in her medical needs themselves and knew she was in a very bad way prior to calling the ambulance service.

The ambulance call recording showed Chantelle had told the call handler her daughter’s oxygen saturation levels were at 50% - but that figure was not recorded properly in the ambulance notes meaning others at the Welsh Ambulance Service (WAS) were unable to ascertain the predicament Robyn was in and decided her call was not an emergency and didn’t require an ambulance at that time.

Ms Saunders told Gillian Pleming, utilisation manager at WAS: “The suggestion there is that an ambulance is not going to be triggered until a clinician has made an assessment." Ms Pleming said that was the case.

Ms Saunders continued: "The way that message might be received is that the clinician might not ring back and an ambulance might not turn up, but if it does it’s likely going to take eight hours. It doesn’t provide any reassurance to the person of what is going to happen.”

Melanie Collier, locality manager for WAS within the clinical support desk, confirmed to Ms Saunders that had the 50% oxygen saturation levels been recorded accurately the call would have been a red call meaning immediately life-threatening and necessitating a response time of eight minutes.

“This should have prompted the next available clinician,” Ms Collier told the inquest. “If the information had been shared with regards to that then there is enough information from that to immediately upgrade that call to a red call without a clinician’s assessment.”

Ms Pleming said since Robyn’s death the service audits calls more and has audited the call handler in this case regularly. One percent of calls are audited, the inquest heard, to ensure call handlers are following the correct protocol where information is put into a system and an algorithm decides the priority level.

“Upon receiving any concerns or investigations we ask for call audits to ascertain if the call was compliant,” she explained. “We know following this case the call handler recorded incorrect information. We go through what could have been done differently to assist their future practice.

“Audits would have been done on a random basis and any concerns about the individual would have been identified. This was a relatively new call handler who hadn’t been at the service for six months.”

Ms Saunders said while it is common for ambulance service staff to end up in inquests giving evidence, health boards need to be questioned more regularly on progress to ensure ambulances aren’t waiting for hours outside emergency units. She said: "I’m reassured by lessons learned by WAS. I’m reassured WAS has made changes to its system to improve response times of ambulances, but I'm still left with the unacceptable delays in handover of patients which results in ambulances not being able to be released to acutely unwell patients.”

Robyn’s medical cause of death was recorded as lower respiratory tract infection contributed to by chronic lung disease. Ms Saunders formally concluded Robyn died from natural causes. She added: “There was a failure to record oxygen saturation levels. If this was recorded the call would have received a red priority. Had the process been correctly followed Robyn would have arrived at hospital sooner. But I do not find earlier admission to hospital would have changed the outcome."

Daniel and Chantelle have told Robyn’s story themselves through Instagram page @robyns_rainbow_story. Daniel is taking part in a skydive in August to raise money for Ty Hafan. You can visit his fundraiser and donate here.