'Undoubted failings' by Nottingham hospitals trust in baby death

Teddy's death was recorded as "unascertained" in a narrative verdict by the coroner

There were "undoubted failings" by healthcare professionals in the care of a newborn baby hours before he died, an inquest has heard.

Edward Errington-Rozkalns was a day old when he died in November last year.

Assistant coroner Laurinda Bower said his cause of death was "unascertained" but midwives had failed to monitor his blood sugar levels before going home.

Nottingham University Hospitals (NUH) Trust said it had "learnt lessons and implemented changes" as a result.

Edward, who was known by his family as Teddy, from Nottingham, was born on 23 November last year.

Nottingham Coroner's Court heard he had been induced as a result of concerns about his growth and weighed just 2.52kg (5lbs 5oz) when born.

Ms Bower said his weight should have triggered midwives to place him on the "blood glucose pathway" as he was at increased risk of developing hypoglycaemia.

However, she said the need for close monitoring "was not recognised by multiple health care professionals".

"This led to a failure to monitor baby's blood glucose levels in the early neonatal period, and to his discharge from hospital without any such monitoring having informed the decision as to a safe discharge," she said.

'Undetected error'

Ms Bower said midwives told of how they were not aware of updated guidelines on when a baby should be checked for blood glucose levels and that weight requirements had changed.

She said this misunderstanding had been going on for at least five years.

Ms Bower said there were "multiple missed opportunities to detect this error" and added: "There were undoubtedly failings in Teddy's care.

"This has been accepted by the Trust. The care provided to Teddy failed to comply with local and national guidance, and further, the initial error was not detected despite multiple handovers of care involving multiple autonomous health professionals."

Following the three-day inquest, the family said: "He was a much wanted, and much-loved baby, and our hearts are broken because he is not with us today."

A spokeswoman for them said there "were more questions to be answered" and there would be a separate civil investigation into Teddy's death.

Sharon Wallis from NUH said there had been "lessons learnt" from Teddy's death

Sharon Wallis, director of midwifery at NUH, said: "We have learnt lessons from this and implemented significant changes as part of our ongoing journey to improving maternity services."

She said changes included introducing mandatory recording fields around birthweight, to make sure babies received appropriate care.

The Care Quality Commission (CQC) rated maternity services at NUH "inadequate" last year after it found the Trust had "some areas to address".