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Hospital neglect contributed to baby's death after failure to give routine vitamin


A coroner has ruled that 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, Cambridge, in July 2020 but died seven weeks later having suffered a brain bleed.

The inquest, held in Huntingdon, heard William was born premature at 34 weeks, on 27 July, and his mother had specifically asked about whether he had received a vitamin K shot.

Ms Skinner said "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'."

William stayed in hospital for two weeks, when he was discharged with a nasogastric tube, but became unwell overnight on 11 September and was 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 Hospital.

Ms Skinner said surgery was performed on William but clinicians "believed the damage to his brain was too great and he would never recover."  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.”

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 that the failure to administer it to William "was so serious it can only be characterised as gross."

She added: "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. This was 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."

A spokesman for Cambridge University Hospitals NHS Foundation Trust said it fully accepted the coroner's findings.

The spokesman said: "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."