On 9 January 2020 I commenced an investigation into the death of Lola Sheldrake, also known as Lola Clarke, age 13 days. The investigation concluded at the end of the inquest on Wednesday 12 May 2021. The conclusion of the inquest was:

Medical Cause of Death – 1a severe anaemia 1b haemolytic disease of the newborn 1c maternal anti-c antibodies

Conclusion – From severe anaemia caused by haemolytic disease o the newborn and which developed untreated following her discharge from hospital on 14 December 2019. Lola’s blood count was not checked on or before 20 December 2019, and she was not recalled to hospital for paediatric review on that date after concerns were raised by her health visitor about static weight, despite feeding well.

As noted above, Lola Sheldrake died from severe anaemia caused by haemolytic disease of the newborn and which developed untreated following her discharge from hospital aged 4 days on 14 December 2019. Her haemoglobin levels, tested on 11 December and 14 December 2019 were essentially normal, at 157 and 144. No reticulocyte count was taken. Information about her ongoing risk of developing severe anaemia and the signs and symptoms to look for was not conveyed to Lola’s parents or to those with responsibility for her care in the community. In consequence it was not relayed back by the health visitor to the on-call paediatric registrar during a call made on 20 December 2019 to express concern about the fact that Lola’s weight had remained static, equivalent to birthweight, for 3 days despite apparently feeding well. The facts that, following discharge: (1) Lola’s blood count was not checked on or before 20 December 2019; and (2) Lola was not recalled to hospital for paediatric review on 20 December 2019 more than minimally contributed to her death and were therefore causative of it. Had either of these events occurred, Lola would have been diagnosed with significant anaemia, admitted and transfused before her condition became immediately life-threatening. By the time that her parents appreciated that Lola needed medical treatment, and brought her to the emergency department on 22 December 2019, her severe anaemia had caused damage to her organs such that it was not survivable. She died on 23 December 2019 at Hinchingbrooke Hospital, Huntingdon, Cambridgeshire.