A four-week-old baby died after being left malnourished and dehydrated by overworked nurses on an understaffed neonatal intensive care unit, an inquest heard.
Lakshith Guptha Nalla died at the University Hospital of Wales in the early hours of May 11, 2024. Pontypridd Coroners’ Court heard the “vulnerable baby” was under-fed and left for hours lying on cold and damp bed sheets before he died.
Coroner Rachel Knight underlined a string of failures by medical staff in the previous days, and said the “persistent and gross understaffing” of the unit left the baby without food for four hours, meaning no one noticed he developed an infection or that he was lying on cold, wet bedding.
It was not until after it had been removed that 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 Island Ward, which is around five minutes away, and take six 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 baby Nalla.
But as she was “in a rush” to go and 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.
It was 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 NICU.
As well as no food, baby Nalla’s paperwork was also missing in parts, including, most crucially, any observations between 4 pm and 5 pm on May 9, reported WalesOnline.
At around 4 pm, another nurse realised that baby Nalla “seemed different.” Blood samples were taken, and the results were described as “worrying” as he was found to be hypoglycaemic and to be suffering from metabolic and respiratory acidosis. He was also found to be cold.
At 6 pm, staff noticed baby Nalla 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 that 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 25-30 per cent, and so even less for baby Nalla, who was trying to fight it alongside two other conditions – all while being hypoglycaemic, malnourished, dehydrated, and cold.
Ms Knight described baby Nalla’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. No evidence being fed as prescribed could have saved baby Nalla.
Ms Knight came to a narrative conclusion for baby Nalla’s death. The 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.
Baby Nalla’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 from happening to other babies.
This poor baby was at such high risk and should have been given the highest care.
Neonatal Intensive Care Unit (NICU) nurses do not deliver babies.
Their primary function is to deliver specialised care to babies who are premature, sick, or need intensive medical attention. While they may assist in emergencies or during scheduled cesarean sections. The emphasis is on the newborns. Why was this nurse needed at a delivery, and why wasn’t another nurse sent?
These were undoubtedly understaffed nurses, but aren’t babies in such critical condition meant to be monitored 24 hours a day, just like an adult in the ICU? Something seems off here.
In this case, the baby may not have made it anyway, but his parents will always wonder, and it’s bad enough to have the heartbreak of losing a child, but to also know that not everything was done to help this child, and also to find out that your baby spent his last hours cold, wet and hungry is simply appalling.
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