A coroner has heard how a four-week-old baby died after being left under-fed and lying on cold, damp bedding in an understaffed neonatal intensive care unit at a major Welsh hospital.
Systemic Failures in Critical Care
Lakshith Guptha Nalla died at the University Hospital of Wales in Cardiff in the early hours of May 11, 2024. An inquest at Pontypridd Coroners' Court was told that 'persistent and gross understaffing' on the unit meant the vulnerable infant went without feed for four hours. Coroner Rachel Knight said the staffing crisis also meant no one noticed he had developed an infection or that he was lying on cold, wet sheets.
The court heard that nurse Pasqualina Mollo, responsible for the baby's care, had disconnected his feeding tube to allow him to be cuddled by his parents, despite him being prescribed a constant feed. When it came time to reattach it, staff discovered there were no new feeding lines available on the ward due to a 'chaotic' stocking system and a failed delivery.
Missed Opportunities and Fatal Errors
Ms Knight said she found it 'surprising that feeding tubes were not available on the biggest neonatal ward in Wales,' describing them as a basic essential. Nurse Mollo had to retrieve tubes from another ward, a process that took around an hour and a half. In a rush to help deliver another baby, she then mistakenly failed to fit the new tube properly.
The nurse did not inform anyone of the missed feed or conduct vital blood tests. The inquest heard staff on the ward were 'asked to do too many jobs' and were looking after twice the recommended number of patients. Crucial paperwork was also missing, including observations for a key period on May 9.
Another nurse had noted baby Nalla 'seemed different' around 4pm that day. Subsequent blood tests revealed 'worrying' results: he was suffering from hypoglycemia, metabolic and respiratory acidosis, and was cold. It was not until 6pm that staff realised his feed had been disconnected for four hours, his tube was leaking, and he was 'lying on cold wet bed sheets'.
A 'Wholly Inadequate' Standard of Care
Coroner Rachel Knight described the care provided as 'wholly inadequate' due to a cascade of failures. The period without feed would have critically impeded the baby's ability to fight infection, as he was forced to use his own extremely limited reserves.
The survival rate for sepsis in premature babies is only 25 to 30 per cent. Baby Nalla was trying to fight it alongside other conditions while being hypoglycaemic, malnourished, dehydrated, and cold. His official cause of death was recorded as sepsis, peritonitis, and necrotising enterocolitis.
The coroner concluded that while baby Nalla should have been nursed at a one-to-one ratio, staffing levels and missing equipment meant he was not cared for to the required standard. She noted, however, that there was insufficient evidence to legally prove the feed issues directly contributed to his death, calling it an 'unfortunate coincidence'.
The baby's father told the court in a statement that the family had moved to Cardiff dreaming of a life in the UK, but have since returned to India following their son's death. He requested his son's body be donated to science in the hope of preventing similar tragedies. The health board has outlined changes to staffing and stocking procedures in the NICU to the coroner.
