Heartbreak as baby dies after being left on cold and wet bed sheets for hours | UK | News
A four-week-old baby died after being left on cold, wet sheets for several hours in a critically understaffed neonatal intensive care unit. Lakshith Guptha Nalla was malnourished and dehydrated when she passed away during NICU “care” at the University Hospital of Wales in Cardiff.
The inquest at Pontypridd Coroner’s Court heard how Lakshith died in the early hours of May 11, 2024, a day that changed his parents’ lives “forever”. Wales Online. Coroner Rachel Knight told the court a series of failures due to “persistent and serious understaffing” led to the four-month-old baby being left without food for four hours, with no staff noticing he had developed an infection as he lay in the cold, wet bed.
Laskhith was said to be “completely NICU dependent” and an example came two days ago when Pasqualina Mollo, the nurse in charge of the child’s care, disconnected his feeding tube to allow his parents to cuddle with him despite his need for constant feeding.
Nurses later realized the ward lacked new supply lines due to a “chaotic” stocking system. The team eventually managed to retrieve six more tubes from another ward.
Ms Knight added: “I find it surprising that the largest neonatal ward in Wales does not have feeding tubes.”
After an hour and a half, Nurse Mollo managed to insert new tubes into the sick four-month-old baby, but was unable to fully insert the tubes as she was “in a hurry” before being called to deliver another baby.
He also did not inform anyone about the missed food or perform any blood tests to see how the child was affected.
The inquest heard how nurses on the unit were understaffed and overstretched, with the hospital asking them to care for twice as many patients as a properly staffed NICU required, and that “staff on the ward were being asked to do too much work during their shifts”.
Moreover, a routine observation was missed between 16:00 and 17:00. Another nurse noticed that the baby’s condition appeared to have changed at 4pm when tests were performed which revealed that Lakshith was hypoglycemic and suffering from metabolic and respiratory acidosis.
At 6pm the nurses noticed his feeding tube was leaking and his sheets were cold and wet.
The court heard that the survival rate for premature babies with sepsis was only 25-30% and Lakshith was battling two other illnesses while being cold, dehydrated and malnourished.
Stating that the care of baby Nalla was “completely inadequate” and that the mistakes that led to her death were “unfortunate coincidences”, Knight stated that the issue of negligence cannot be resolved legally by a very narrow margin.
When the official cause of death was announced, it was determined that Lakshith died of sepsis, peritonitis, and necrotizing enterocolitis; There was no evidence to suggest that the prescribed food could save the baby.
The coroner ruled they had reached a narrative conclusion regarding her death and said: “Baby Nalla was born at 30 weeks and 4 days gestation with a congenital condition that required surgery. This surgery was performed the day after she was born and she was making a full recovery.”
“Baby Nalla had to be breastfed at a one-to-one ratio according to the instructions. Due to the staff density in the service and the lack of equipment, she was not cared for at the required standard for 4 hours and was not fed at all.
“She was showing signs of necrotizing enterocolitis, which was the likely cause of death. There is insufficient evidence that complications related to Baby Nalla’s feeding contributed to her death.”
Since the incident the medical board has made changes to stocking and staffing in the NICU, which is said to have satisfied the coroner.
The court heard from Lakshith’s father that they moved to Cardiff to pursue a dream but returned to India after their child’s death.
