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A coroner has found there was “gross failure in medical care amounting to neglect” in the death of a baby who was not given a routine vitamin after birth.
William Moris-Patto was born at Addenbrooke’s Hospital in Cambridge in July 2020 but died seven weeks later having suffered a brain bleed.
Coroner Lorna Skinner KC said he would not have died had he been given vitamin K, needed for blood clotting.
The hospital trust has apologised.
The inquest, held in Huntingdon, heard William was born premature at 34 weeks, on 27 July, and his mother had specifically asked about whether William had received a vitamin K shot.
“So far as she can recall, when she asked if William had had all the necessary postnatal checks and care, a female member of the… staff said ‘yes, everything’s been done’,” Ms Skinner said.
William stayed in hospital for two weeks, when he was discharged with a nasogastric tube, but became unwell overnight on 11 September and had been sick.
His parents, from Chatteris, rang the NHS 111 service, which in turn led to an ambulance being called and William was taken to Addenbrooke’s.
Ms Skinner said surgery was performed on William but clinicians “believed the damage to his brain was too great and he would never recover”, and he died on 17 September.
The coroner said she had heard from his mother Naomi Moris that William’s death was “nothing short of devastating”.
‘Erroneous entry’
Ms Skinner told the inquest that vitamin K administration had been a “routine part of newborn care for many years”.
She said that all babies are born with a vitamin K deficiency and said the failure to administer it to William “was so serious it can only be characterised as gross”.
“It was not just compounded, but for all practical purposes rendered irremediable, by the erroneous entry on his admission record that he had had it,” Ms Skinner said.
“This was neglect. Neglect which occurred in circumstances where otherwise the care and treatment given to William could not be faulted.”
In a narrative conclusion, Ms Skinner said: “William died of natural causes – a vitamin K deficiency which caused a spontaneous intracranial haemorrhage.
“His death was contributed to by neglect in that he was not given vitamin K after birth and if he had been, he would not have died.”
Samantha Critchley, from legal firm Fieldfisher which represented the family, said: “An audit of births around the same time showed 27 other babies were recorded as not having had vitamin K.
“It is hugely disappointing to hear that three years later, accurate vitamin K records across the midwifery and neonatal units at the trust are still missing.”
A spokesman for Cambridge University Hospitals NHS Foundation Trust said it fully accepted the coroner’s findings.
“The trust remains deeply saddened by William’s tragic death and wishes to express its sincere condolences and apologies to his family at this difficult time.
“Processes were, and continue to be, constantly reviewed to ensure a similar error cannot be made in the future. If, following further review, the coroner has any concerns, these will be addressed.”
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