Baby's death could have been avoided - coroner

A premature baby "would have survived" had he received better care in hospital, a coroner has ruled.

Teddy Martin - who was born at 31 weeks - was 35 days old when he suffered a cardiac arrest at Nottingham's Queen's Medical Centre (QMC) on 5 September 2023.

He had to be resuscitated after a procedure to change his breathing tubes had failed, the inquest heard.

A spokesperson for Nottingham University Hospital NHS Trust (NUH) said it had implemented changes to help prevent this from happening in the future following an investigation.

Teddy was born with a genetic condition that gave him an enlarged tongue, and made breathing difficult.

While on the high dependency unit of the QMC's neonatal department, he was kept on ventilation to aid breathing.

When Teddy was stable, concern over secretions blocking his oral breathing tube led to the decision to replace it with a nasal version.

While the procedure was an "appropriate" step, assistant coroner Elizabeth Didcock said, not enough contingency planning was in place.

The nasal tube was dislodged "accidentally", and Teddy's airway was obstructed due to his genetic condition.

Concluding the inquest at Nottingham Coroner's Court on Friday, she said a series of failings had led Teddy's condition to deteriorate "rapidly", following the earlier unsuccessful procedure.

The coroner told the hearing the plan in place to rescue Teddy in case re-intubation failed was "insufficient".

A lack of formal identification of the baby's difficult airway, as well as having no paediatric anaesthetist on standby while the procedure was undertaken, had made "more than a minimal contribution to Teddy's death", the coroner added.

She had also criticised the lack of documentation and planning prior to the procedure, and said she found it "unlikely" the risk assessment was communicated to the family.

In a statement read out on the steps of Nottingham Council House steps on behalf of Teddy's family, their lawyer said: "We're heartbroken by the tragic loss of our son Teddy.

"We have fought tirelessly to understand why he died, and we now know it was due to avoidable failures in his care."

The family previously said they had to wait months for an internal report into what had happened, eventually enlisting the help of Donna Ockenden, head of the inquiry into maternity failings at the trust, to have it handed over.

Dr Manjeet Shehmar, on behalf of the health trust, said: "I would like to offer my sincere condolences to Teddy Martin's family on what must be an incredibly difficult day.

"We fully accept the coroner's findings and are truly sorry that the care delivered on the day of Teddy's death did not meet the standards his family expected and deserved."

She added the trust had discussed its review with Teddy's family, saying changes had already been implemented.

Dr Shehmar said: "Changes made as a result include creating a new neonatal airway lead in the team, making improvements to the current intubation checklist and reviewing ventilation guidance with colleagues on the ward as well as changes in supporting learning through investigations."

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