Hospital failings and neglect contributed to baby's death, coroner finds

Hospital failings and "neglect" contributed to the death of a two-day-old baby, a coroner has found.

Cassian Curry was born in Sheffield Teaching Hospitals' Jessop Wing maternity unit on 3 April last year.

An inquest heard how he deteriorated rapidly and died, with a feeding tube being left in a "sub-optimal" position.

On Friday, assistant coroner Abigail Combes concluded that a failure to record and share information about his care contributed to his death.

Cassian was born at 28 weeks and was "very small, even for his age" at 1lb 10oz (750g), the inquest in Sheffield heard.

In evidence, it was said Cassian died from a cardiac tamponade, which is when fluid builds up in the space around the heart, eventually preventing it from pumping.

The inquest heard following his birth Cassian had a feeding tube - called a umbilical venous catheter - inserted into his abdomen, but that it was in a "sub-optimal" position near his heart when it was inserted by two junior doctors.

Neo-natal consultant Dr Elizabeth Pilling told the inquest earlier she had intended to have it repositioned within 24 hours.

She said she had initially waited because of the dangers of repeatedly handling a baby as premature as Cassian but had no explanation as to why she then forgot to make sure it was moved.

Giving her conclusion, Ms Combes said the decision to pause the procedure and reassess it in 24 hours was "reasonable and appropriate", but was "not adequately recorded and communicated" in Cassian's notes, or on the ward round.

Ms Combes said that this amounted to a "gross failure" in Cassian's care, and one which contributed to his death.

She added: "But for this incident, Cassian would not have died of what he died of, when he died."

The coroner recorded a narrative conclusion, which said Cassian's death was "contributed to by neglect".

Ms Combes found there were no systemic failures in the form of staffing issues which caused or contributed to Cassian's death, following concerns raised by Cassian's parents.

The medical director of Sheffield Teaching Hospitals NHS Foundation Trust, Dr Jennifer Hill, described the circumstances surrounding Cassian's death as "a very rare incident" and said all those involved were "devastated"

She said steps had been taken to limit the chances of this happening again.

After the hearing, Cassian's parents, Karolina and James Curry, said their son was "a true miracle" after being born following six rounds of IVF.

"Today, the Coroner concluded that he died because of neglect, and had it not been for the gross failings of those in charge of his care, he would still be with us today," they said in a statement.

"We will love and miss him forever."

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