The BBC attended the inquest into the death of baby William Moris-Patto last week in Cambridgeshire and reported the coroner's conclusion that 'gross failure in medical care amounting to neglect' caused William's death.
Coroner Lorna Skinner KC told the court that William would not have died had he correctly been given vitamin K, a standard injection for newborns before they are discharged home.
William was born at Addenbrooke's Hospital in Cambridge, part of Cambridge University Hospitals NHS Foundation Trust, in July 2020. He died seven weeks later having suffered an intracranial haemorrhage (brain bleed) known as vitamin K deficiency bleeding or VKDB.
Up to 1.7 per cent of babies who do not have a vitamin K shot at birth will develop VKBD, which is linked to high rates of infant deaths.
An external investigation into William's death showed that despite his notes recording that he had been given the injection, he did not receive vitamin K.
Ms Skinner told the inquest that all babies are born with a vitamin K deficiency and said the failure to administer it to William 'was so serious it can only be characterised as gross'.
'It was not just compounded, but for all practical purposes rendered irremediable, by the erroneous entry on his admission record that he had had it,' Ms Skinner said.
'This was neglect. Neglect which occurred in circumstances where otherwise the care and treatment given to William could not be faulted.'
Samantha Critchley who represented Naomi and Alex Moris-Patto at the inquest added that:
'An audit of births around the same time showed 27 other babies were recorded as not having had vitamin K.'
'It is hugely disappointing to hear that three years later, accurate vitamin K records across the midwifery and neonatal units at the trust are still missing.'
A spokesman for Cambridge University Hospitals NHS Foundation Trust said it fully accepted the coroner's findings. The Trust has apologised to the family.
The civil case is ongoing.
The Guardian and the Times also reported the case.
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