The parents of a baby who died two days after being born have questioned whether staffing issues contributed to their son's death, an inquest heard.
Cassian Curry died at Sheffield Teaching Hospitals' Jessop Wing neo-natal unit in April 2021.
Cassian was born at 28 weeks and weighed 1lb 10oz (750g).
His parents said they had several concerns about his treatment, including reports the unit was understaffed due to it being the Easter weekend.
The inquest at Sheffield's Medico Legal Centre heard Cassian died on 5 April 2021.
The previous month the Trust's maternity services had been rated inadequate by the Care Quality Commission (CQC), though the neo-natal unit was not part of the inspection.
In a statement Karolina Curry said she and her husband, James, had concerns following reports the unit was short staffed and that medics failed to act on her concerns, including about her son's raised heart rate. "We still can't get our heads around any of this and how a bank holiday means your child dies," she said. We cannot understand why they can't have life-saving checks or the right number of staff because of a bank holiday."
Following his birth on 3 April, Cassian was placed on total parental nutrition, a routine step for premature babies, which was delivered by an umbilical venous catheter. The inquest will examine whether the catheter was incorrectly sited too close to Cassian's heart and if there was a failure to review its position and move it.
Mrs Curry said she twice noted that her son's heart rate increased to more than 200 beats per minute but was told by medical staff that it was nothing to worry about. She said she also worried that Cassian had not produced any bowel movements and this was a sign that he was not feeding properly.
In the statement read by assistant coroner Abigail Combes, Mrs Curry she said the "whole process" from her son's birth to his death "seemed chaotic".
A CQC inspection of maternity services found the it did not have enough midwifery staff with the "right qualifications, skills, training and experience".
Ms Combes said the findings will be referred to in the inquest but stressed that the two inquiries had different remits.
UPDATE PUBLISHED BY THE SHEFFIELD STAR NEWSPAPER
'Small but strong' Cassian was born in Sheffield Teaching Hospitals' Jessop Wing maternity unit on April 3 last year at 28 weeks, weighing 1lb 10oz.
An inquest last week heard how Cassian deteriorated rapidly on April 5 and died from a cardiac tamponade, which is when fluid builds up in the space around the heart, eventually preventing it from pumping. The coroner then ruled that hospital failings and 'neglect' contributed to the death of the baby boy.
The hearing was also told how an umbilical venous catheter inserted into Cassian's abdomen to help him feed was in a ‘suboptimal’ position near his heart when it was inserted by two junior doctors.
Neonatal consultant Dr Elizabeth Pilling told the inquest she had intended to have it re-positioned within 24 hours, but waited because of the dangers of repeatedly handling a baby as premature as Cassian. Dr Pilling said she had no explanation as to why she then forgot to make sure his feeding line was moved.
Giving her conclusion, Ms Combes said the decision to pause the procedure and reassess it in 24 hours was ‘reasonable and appropriate’, but was ‘not adequately recorded and communicated’ in Cassian's notes, or on the ward round. The plan should have been recorded on Cassian's ‘pink sheet’, she said, and communicated to his parents. Ms Combes said this amounted to a ‘gross failure’ in Cassian's care, which contributed to his death. She added: "But for this incident, Cassian would not have died of what he died of, when he died."
The coroner recorded a narrative conclusion, which said Cassian's death was ‘contributed to by neglect’.
In a statement at the start of the hearing, Cassian's mother, Karolina Curry, said she and her husband James had a number of questions about her son's treatment, including reports that the unit was understaffed due to it being the Easter weekend. But Ms Combes concluded: "There were no systemic failures in the form of staffing issues which caused or contributed to Cassian's death." She said the staffing levels were above the national requirement that weekend, and although there were a number of junior staff present, they were ‘appropriately qualified and able to support the unit adequately’.
The medical director of Sheffield Teaching Hospitals NHS Foundation Trust, Dr Jennifer Hill, has said the trust is ‘so very sorry for what happened’ to Cassian, admitting there was ‘human error in terms of the management of Cassian's umbilical venous catheter’. Following the inquest, Dr Hill said there had been a full review, changes had already been made and it would take on board any further recommendations from the coroner.
She said: "This was a very rare incident to have happened and everyone involved in his care is devastated.
"There has been a full review of what happened, and changes have already been made to limit the chances of this happening again including additional consultant support at weekends and ongoing improvements to the documentation used. "We will also be taking on board any further recommendations from the coroner and ensuring we respond with appropriate actions."
Mr and Mrs Curry have said Cassian was ‘a miracle for us’ when they found out he was on his way after six cycles of IVF. Following the conclusion, the boy's parents said: "Cassian was a beacon of light and our hearts blossomed under his pure and innocent love. He was everything that we dreamed of. Today, the coroner concluded that he died because of neglect, and had it not been for the gross failings of those in charge of his care, he would still be with us today. Cassian was a true miracle, and we will love and miss him forever."
Fay Marshall, a solicitor at Switalskis Solicitors, who represented the family at the inquest, said: “While the trust has made changes in the last year the coroner did not think they went far enough, and she will be issuing a prevention of future deaths report.
“James and Karolina have sat patiently and listened to the evidence this week and they do have some answers, but nothing can bring Cassian back. Nothing can lighten their grief over what happened and how it happened. “Cassian’s death was avoidable. He was a strong baby who should have gone home with his parents who had tried for years to start their family. James and Karolina want to make sure the trust makes changes so that no other family has to go through this.”