A newborn baby was left under-fed and lying on cold damp bed sheets in a hospital’s understaffed neonatal intensive care unit before he died, an inquest has heard.
Lakshith Guptha Nalla was just four weeks old when he died at the University Hospital of Wales in the early hours of May 11, 2024, after nurses failed to feed him sufficiently.
The ‘persistent and gross understaffing’ of the unit left the ‘vulnerable’ baby without feed for four hours and meant no one noticed he developed an infection or that he was lying on cold wet bedding, coroner Rachel Knight said.
She also said that nurse Pasqualina Mollo, who was responsible for feeding the ‘vulnerable’ baby, disconnected the feeding tube to allow the infant to cuddle its parents although he was prescribed constant feed.
It was not until after it had been removed they noticed that there were no new feeding lines on the ward at the time.
This was due to their ‘chaotic’ stocking systems and because a delivery had not turned up.
Ms Knight said: ‘I find it surprising that feeding tubes were not available on the biggest neonatal ward in Wales,’ adding that they are a basic essential.
Nurse Mollo had to call another ward, which is around five minutes away, and take six tubes from there.
It was not until an hour and a half later that they actually got the tubes which is when Nurse Mollo fitted the new one on little Lakshith.
But as she was ‘in a rush’ to help deliver another baby she mistakenly did not fit his feeding tube properly.
She also did not inform anybody of the hours of feed he missed or conduct blood tests to ensure the hours without food had not affected his condition.
Pontypridd Coroners’ Court heard that the Lakshith parents’ lives have ‘changed forever’ since his death.
The inquest heard that ‘the staff on the ward were asked to do too many jobs during their shift’ and they were made to look after twice the number of patients they should be looking after in the unit.
As well as no food the baby’s paperwork was also missing in parts including, most crucially, any observations between 4pm and 5pm on May 9.
At around 4pm another nurse recognised baby Lakshith ‘seemed different’.
Blood samples were taken and the results were described as ‘worrying’ as he was found to suffer from hypoglycemia and with metabolic and respiratory acidosis. He was also found to be cold.
At 6pm staff noticed Lakshith was not connected to his feed properly and hadn’t been for the past four hours. They saw his feeding tube was leaking and that ‘he was lying on cold wet bed sheets’.
The court heard the impact of this period with no feed would have impeded the baby’s ability to fight off any infection as he was using his own reserves, which were extremely limited due to his vulnerability and his size.
The survival rate of sepsis in premature babies is around 25 to 30 per cent and so even less for Lakshith who was trying to fight it alongside two other conditions – all while being hypoglycaemic, malnourished, dehydrated, and cold.
Ms Knight described baby Lakshith’s care as ‘wholly inadequate’ due to the failures and missed opportunities, most notably where he went four hours with no feed.
She said his lack of care in the days before his death was an ‘unfortunate coincidence’ and added the issue of neglect could not be legally made out by a very narrow margin.
The child’s cause of death was given as sepsis, peritonitis, and necrotising enterocolitis. There was no evidence that being fed as prescribed could have saved the baby.
The inquest’s conclusion stated: ‘Baby Nalla was born at 30 weeks and four days gestation with a congenital condition that required surgery. This surgery was undertaken the day after he was born and he was making a full recovery.
‘Baby Nalla should have been nursed at a one-to-one ratio as per the guidelines. Due to staffing levels on the ward and missing equipment he was not nursed to the standard he should have been and was not fed at all for four hours.
‘He was showing signs of necrotising enterocolitis, which is likely his cause of death. There is insufficient evidence that the complications surrounding baby Nalla’s feed contributed to his death.’
With regard to the prevention of future deaths Ms Knight said she was satisfied with the health board’s changes to stocking and staffing at the NICU. The health board is expected to be sending Ms Knight a letter further outlining these changes.
Lakshith’s father said in a statement read to the court earlier in the hearing that he and his family had dreamed of a life in the UK which is why they moved to Cardiff but after losing their son they have moved back to India.
He asked for his son’s body to be donated to science in the hope it may prevent the same thing happening to other babies.
