Finding into death of Noah Philip James Sheekey

<1y · Male·Escherichia Coli sepsis in a low birth weight infant

Noah Sheekey, a small-for-gestational-age neonate, died of E. coli sepsis at 3 days old, one day after discharge from hospital. Although his initial condition was reassuring, he was managed on the postnatal ward rather than special care nursery. Critical gaps in care included: lack of paediatric team involvement in discharge decision-making, absence of vital sign monitoring after initial assessment, no pre-discharge paediatric examination, and discharge without paediatric follow-up documentation. The independent expert found that whilst the decision for ward care was initially reasonable, subsequent protocols were inappropriate for an SGA infant. Had Noah remained hospitalised on the evening of 9 January or received closer paediatric supervision, earlier detection of infection symptoms may have enabled earlier intervention, potentially altering outcome. The hospital subsequently implemented substantial protocol changes requiring mandatory paediatric team involvement in all 'qualified' baby discharges.