Coroner's court: Low staff and supplies contributed to preemie's NICU death

A Wales court heard a case last week in which a hospital was alleged to have neglected a NICU patient so severely that the infant died after experiencing starvation and dehydration.

Key Takeaways:

• After a NICU infant in Wales died in May 2024, a coroner's investigation revealed he had experienced both starvation and dehydration.

• An inquest further revealed the hospital experienced "persistent and gross understaffing" at the time of the infant's death.

• The hospital has reportedly made changes to staffing since the incident occurred.

The Details:

Lakshith Guptha Nalla was just four weeks old in the neonatal intensive care unit (NICU) at University Hospital of Wales when he died in May of last year, according to a case heard last week in Pontypridd Coroners’ Court.

Coroner Rachel Knight, who described Nalla as "vulnerable" and "entirely dependent on the NICU," said there were a series of medical failures in the NICU, along with "persistent and gross understaffing," prior to his death.

According to Knight, Nalla had been left without nutrition for four hours after harried staff didn't have a feeding tube to offer him and weren't regularly checking on him.

The nurse responsible for Nalla's care, Pasqualina Mollo, had allegedly disconnected the infant's feeding tube so that he could cuddle with his parents, but a new tube was not placed right away because there were no spares in the unit due to what Knight described as a "chaotic" stocking system.

"I find it surprising that feeding tubes were not available on the biggest neonatal ward in Wales," Knight said.

When a new feeding tube was located, it was not connected properly, and staff were not aware of the problem for hours. In addition, no one was aware that Nalla had developed an infection, and it wasn't until hours later that staff noticed the feeding tube was disconnected and that "he was lying on cold wet bed sheets" due to the leaking feeding tube prior to his death.

Zoom In:

Testimony during the inquest found "the staff on the ward were asked to do too many jobs during their shift," with many caring for twice as many patients as they should have been.

Though the coroner's investigation could not conclusively determine that the hospital's actions led directly to Nalla's death — his death was determined to be due to sepsis, peritonitis, and necrotising enterocolitis — Knight called his care "wholly inadequate" and said the hours without food would have impacted his ability to fight infection due to his vulnerability and size.

"Baby Nalla was born at 30 weeks and four days gestation with a congenital condition that required surgery. This surgery was undertaken the day after he was born and he was making a full recovery," read Knight's conclusion.

"Baby Nalla should have been nursed at a one-to-one ratio as per the guidelines. Due to staffing levels on the ward and missing equipment he was not nursed to the standard he should have been and was not fed at all for four hours. He was showing signs of necrotising enterocolitis, which is likely his cause of death. There is insufficient evidence that the complications surrounding baby Nalla's feed contributed to his death."

The hospital has reportedly made changes to its staffing and procedures following Nalla's death.

The Bottom Line:

The tragic incident is a reminder that in order for infants to thrive, neonatal facilities need the support necessary to provide the best care possible.