A seven-week-old baby boy who died from a bleed in the brain after medics failed to give him a routine injection was ‘neglected’, a coroner has ruled.
William Moris-Patto was born premature at 34 weeks in July 2020 at Addenbrooke’s hospital in Cambridge, but died on September 17 after suffering a brain haemorrhage.
His parents, Naomi and Alex Moris-Patto have now spoken of their devastation, after an inquest ruled he had died from ‘neglect’.
The inquest this week found that William would not have died had he been given a routine injection of vitamin K, which is needed for blood clotting.
While all babies require some level of Vitamin K post-birth, premature babies are even more in need because of higher levels of deficiencies.
Following his birth, it was incorrectly recorded that he had received a vitamin K injection. The NHS advises that all newborn babies receive additional vitamin K to aid blood clotting.
Coroner Lorna Skinner KC found there was ‘gross failure in medical care amounting to neglect’ in relation to William’s death.
Naomi said: ‘The finding that neglect led to his death is devastating.
‘There’s no way we can bring William back but we hope this stands to stop this ever happening again.’
The hospital trust has apologised to Naomi and Alex for its failures.
The inquest, held in Huntingdon, Cambs, heard William was born premature at 34 weeks on July 27 and that Naomi specifically asked whether her son had received a vitamin K shot.
Ms Skinner said as far as Namoi recalled when she asked if William had had all the necessary postnatal checks and care, a female member of the staff said ‘yes, everything’s been done.’
William stayed in hospital for two weeks before being discharged with a nasogastric tube.
However, he then became unwell overnight on September 11.
His parents, from Chatteris, rang the NHS 111 service and an ambulance was dispatched which took William to Addenbrooke’s hospital for surgery but clinicians ‘believed the damage to his brain was too great and he would never recover.’
William died on September 17 2020.
Naomi said: ‘It’s hard to summarise how we feel but we were impressed at how thorough the process was.
‘It’s a bit of a relief to have it over with, it’s a mix of emotions.’
Alex said: ‘I think there are still concerns for us, we still think there is a risk for future deaths because of the systematic errors that were at play.’
In a narrative conclusion, Ms Skinner said: ‘William died of natural causes – a vitamin K deficiency which caused a spontaneous intracranial haemorrhage.
‘His death was contributed to by neglect in that he was not given vitamin K after birth and if he had been, he would not have died.’
Cambridge University Hospitals NHS Foundation Trust said it fully accepted the coroner’s findings.
A spokesman said ‘The trust remains deeply saddened by William’s tragic death and wishes to express its sincere condolences and apologies to his family at this difficult time.
‘Processes were, and continue to be, constantly reviewed to ensure a similar error cannot be made in the future. If, following further review, the coroner has any concerns, these will be addressed.’