A premature baby died after being left without food for four hours and lying on cold, wet bed sheets in an understaffed neonatal intensive care unit, a coroner's court has heard.
A Series of Failures in Care
Lakshith Guptha Nalla, born at just 30 weeks and four days gestation, was four weeks old when he died in the early hours of May 11, 2024 at the University Hospital of Wales in Cardiff. An inquest at Pontypridd Coroners' Court detailed a cascade of errors in his care.
Coroner Rachel Knight described "persistent and gross understaffing" on the unit, which meant nurses were looking after twice the recommended number of patients. This critical shortage led directly to the infant being left without his prescribed constant feed for a prolonged period.
Chaotic Systems and Missed Opportunities
The court heard that on May 9, 2023, nurse Pasqualina Mollo disconnected baby Nalla's feeding tube so his parents could cuddle him. It was then discovered there were no replacement feeding tubes available on the ward due to a "chaotic" stocking system and a missed delivery.
Ms Knight stated she found it "surprising that feeding tubes were not available on the biggest neonatal ward in Wales." Nurse Mollo had to fetch tubes from another ward, a process that took an hour and a half. In a rush to assist with another delivery, she then fitted the new tube incorrectly.
She failed to inform colleagues the baby had missed hours of feed or to conduct vital blood tests. His paperwork was also incomplete, with observations missing for a key period that afternoon.
The Final Hours and Cause of Death
By around 4pm, another nurse noted baby Nalla "seemed different." Tests revealed he was hypoglycemic, suffering from metabolic and respiratory acidosis, and was cold. At 6pm, staff finally discovered his feeding tube was leaking and he had been lying on cold, wet bed sheets, having been improperly connected for four hours.
The lack of nutrition severely impaired his ability to fight infection, as he was forced to use his own extremely limited reserves. The coroner concluded his care was "wholly inadequate."
The cause of death was recorded as sepsis, peritonitis, and necrotising enterocolitis. The survival rate for sepsis in premature babies is only 25-30%, and baby Nalla was trying to fight it while also hypoglycemic, malnourished, dehydrated, and cold.
In a narrative conclusion, Ms Knight said baby Nalla, who had successfully undergone surgery after birth, should have been nursed at a one-to-one ratio. She stated: "Due to staffing levels on the ward and missing equipment he was not nursed to the standard he should have been."
She added that while neglect could not be legally made out by a very narrow margin, the lack of care was an "unfortunate coincidence" of failures. There was no evidence that being fed as prescribed would have saved him.
Aftermath and Family's Anguish
The coroner said she was satisfied with the health board's subsequent changes to staffing and stocking procedures. Baby Nalla's father, in a statement read to the court, said the family had moved to Cardiff dreaming of a life in the UK but have since returned to India after losing their son.
In a final, heartbreaking act, the family requested their son's body be donated to science in the hope it might prevent similar tragedies for other babies.
