An inquest has heard that a four-week-old baby died after being left without food for four hours on cold, wet bedding at the understaffed neonatal intensive care unit (NICU) of the University Hospital of Wales in Cardiff. Lakshith Guptha Nalla passed away in the early hours of 11 May 2024, with the coroner citing persistent and gross understaffing as a key factor in the failings that led to his death.
The inquest was told that on 9 May, nurse Pasqualina Mollo disconnected the baby's feeding tube to allow him cuddle time with his parents, despite him being prescribed continuous feed. No new feeding lines were available on the ward due to a chaotic stocking system and a missed delivery, forcing the nurse to source tubes from another ward. It took an hour and a half to fit a new tube, and when it was fitted, it was incorrectly placed. The nurse failed to report the missed feeding or carry out blood tests.
Staff on the ward were caring for double the number of patients they should have been, and baby Nalla's observations were missing between 4pm and 5pm on 9 May. Around 4pm, another nurse noticed he seemed different; blood tests revealed he was hypoglycaemic, suffering from metabolic and respiratory acidosis, and was cold. At 6pm, staff realised his feed had not been properly connected for four hours and he was lying on cold, wet sheets.
Coroner Rachel Knight said the period without feeding would have hampered the baby's ability to fight infection, and described his care as wholly inadequate. She reached a narrative verdict, stating the death was due to sepsis, peritonitis, and necrotising enterocolitis, but added that neglect charges could not be legally established. The baby's parents said their lives have been changed forever.
