Glan Clwyd diesel fumes didn't contribute to death of baby - inquest

Annie-Jo Mountcastle died at her family’s home in Llanfair Talhaiarn on November 17, 2017, having been born at 28 weeks’ gestation on February 5 at the Bodelwyddan hospital.

Following a full inquest into her death, held at County Hall, Ruthin today (July 10), John Gittins, senior coroner for North Wales East and Central, recorded a conclusion of death arising from natural causes.

The baby’s medical cause of death was stated as sudden infant death syndrome, contributed to (but not directly related to) by bronchopulmonary dysplasia (BPD – a form of chronic lung disease).

During the inquest, it was heard Annie-Jo and her twin sister, Florence-Rose, developed BPD after their births.

Amy Dean with her daughter, Annie-Jo Mountcastle (Image: Family handout)

Amy Dean, the twins’ mother, said her daughters were placed in “room two” on Glan Clwyd’s Special Care Baby Unit, while works concerning a neonatal unit at the hospital were being carried out simultaneously by BAM Construction.

Ms Dean recalled “clouds of dust and particulates in the air”, as well as the “strong smell of fumes, like diesel” emanating from the works, which were taking place outside but adjacent to the room her daughters occupied.

She said she and her then-partner, David Mountcastle (Annie-Jo’s father), made repeated requests for windows in the room to be shut, telling staff of the potential harm they felt having them open presented.

“I find it very hard to understand why our concerns at the hospital were not acted upon immediately,” Ms Dean said.

“I feel health and safety at Glan Clwyd was not taken seriously enough, particularly where (there were) sick, vulnerable babies in close proximity to substantial building works emitting fumes.”

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'Lied to constantly'

Ms Dean added she felt as if she was “lied to constantly”, and as if she had “been a bad mother”.

A senior nurse at the hospital “rubbished” her and Mr Mountcastle’s claims, she added.

The twins were placed into incubators and later moved to a different room, where the windows were kept shut, after which she said they “immediately started to improve” and required less oxygen therapy.

They were discharged from Glan Clwyd on April 26, 2017; almost three months after their births.

From then on, Ms Dean said she preferred to take her babies to Ysbyty Gwynedd, Bangor for appointments despite this hospital being of considerably further distance from their home than Glan Clwyd.

“We weren’t prepared to expose our babies any longer to hidden killers,” she said.

When checked at Ysbyty Gwynedd on September 22, Annie-Jo’s cardiovascular, respiratory and abdominal systems were found to be normal.

Annie-Jo's siblings sat on her memorial bench on Pensarn Beach (Image: Family handout)

Mr Mountcastle added windows were opened at Glan Clwyd “on a daily basis, for many hours” – the explanation he was given by staff was the inside of the hospital was “extremely hot”.

'Hostility'

He said he raised concerns daily with staff, who told him: “we breathe it in every day”; he added any requests made were “refused” and “met with hostility”.

“We witnessed first-hand what the exposure to pollutants did to our baby girls, and can say without doubt it had a negative impact on their health,” he said.

While Ms Dean and Mr Mountcastle both smoke, they said they always did so outside or, in bad weather, in their kitchen, and never in the direct company of their children.

Dr Geedi Ali Farah, a consultant neonatal paediatrician, said despite being born prematurely, Annie-Jo was initially “in good condition” and “doing very well”.

He added no members of the hospital’s clinical staff reported smelling diesel fumes at the time.

'No specific test'

Specialist advice was sought, which revealed there is “no specific test which could prove or refute exposure to diesel fumes”.

The most appropriate course of action, Dr Farah said, was to continue the care already being provided to Annie-Jo, given there was nothing about her presentation which was “out of character” for a baby born as prematurely as her.

Dr Farah’s opinion was Annie-Jo’s death was not directly linked to her BPD, and said children born prematurely are at increased risk of sudden infant death syndrome.

Paul Virdi, the project manager employed by BAM Construction, said the firm had no control regarding the hospital’s decision to open or close windows, and found no issues with the plant used for the works.

The two pathologists who undertook Annie-Jo’s post-mortem examination were unable to discern a provisional cause of death, meanwhile.

'Ready to be discharged'

Dr Ian Barnard, a consultant paediatrician who was working at the hospital when the twins were born and being cared for there, said Annie-Jo was “ready to be discharged when she was” on April 26.

Expert witness Professor Sailesh Kotecha, professor and head of child health at Cardiff University, agreed Annie-Jo’s initial care was “absolutely fine up to her discharge”.

He added there was no evidence she had any clinical symptoms or problems as a result of her BPD.

Another expert witness, Professor Jonathan Grigg, professor of paediatric respiratory and environmental medicine at Queen Mary, University of London, said there is “no doubt, on at least one day, there were pollutants”.

Professor Grigg added Annie-Jo’s parents’ stance was “quite compatible and plausible”, in that if someone can smell diesel fumes and see particular matter from dust, “there is likely to be a significant pollution event within that environment”.

But he added, in Annie-Jo’s case, “the underlying process of BPD was already in place” before any potential contaminates arose.

While his view is a diesel fume pollutant event did occur, the exact level of this is unknown, because it is practically incalculable.

'Lovely little girl'

Concluding, Mr Gittins offered his condolences to Annie-Jo’s parents on the loss of their “lovely little girl”.

He said: “There is a very understandable and indeed plausible reason why the parents of Annie-Jo should be so concerned about the features of the care and treatment which may have been contributory to the loss of their child.

“I’ve thought very carefully about the challenges this case presented, and at no point have I lost sight of the massive loss you, as parents, have suffered.

“By April 26, Annie-Jo was well enough to be discharged from hospital to her parents’ care at home.

“Between April 26 and her death on November 17, she had not shown signs of any significant respiratory disease.

“There is a considerable gap between Annie-Jo’s discharge and the time of her passing, and in that period of time, all of the evidence points to her being well and properly cared for at home.

“So, there is no association I can make in this case between the contamination at Glan Clwyd and the final passing of Annie-Jo.

“It’s probable that her existing chronic lung disease had made her more susceptible to sudden infant death syndrome, and that her death, therefore, was due to this.”

But, Mr Gittins acknowledged, “It’s clear there would be no reason for Ms Dean and Mr Mountcastle to raise the concerns as they did so at that time, unless they truly believed them to be true.”