A heartbreaking inquest has revealed the tragic circumstances surrounding the death of Lakshith Guptha Nalla, a premature baby who died at just four weeks old. Born at 30 weeks and four days of gestation, baby Nalla was described as 'vulnerable' and was receiving care at the University Hospital of Wales when he passed away in the early hours of May 11, 2024.

The inquest at Pontypridd Coroners' Court uncovered a series of failures by nursing staff in the neonatal intensive care unit (NICU) that contributed to the infant's malnourishment and dehydration. Coroner Rachel Knight highlighted the "persistent and gross understaffing" of the unit, which resulted in baby Nalla going without feed for four hours. This lack of attention also meant that no one noticed he had developed an infection or that he was lying on cold, wet bedding.

On May 9, 2023, nurse Pasqualina Mollo disconnected baby Nalla's feeding tube to allow for parental cuddles, despite the infant being prescribed constant feeding. It was later discovered that there were no new feeding lines available on the ward due to a chaotic stocking system and a missed delivery. Coroner Knight expressed her surprise that feeding tubes were not readily available, stating, "I find it surprising that feeding tubes were not available on the biggest neonatal ward in Wales."

Nurse Mollo had to retrieve feeding tubes from another ward, which took an hour and a half. When she finally fitted a new tube, it was done improperly as she was in a rush to assist with another delivery. She failed to inform anyone about the missed feeds or conduct necessary blood tests to assess the baby's condition after the feeding interruption.

The inquest revealed that the staff were overwhelmed, being asked to care for twice the number of patients they should have been. Additionally, baby Nalla's paperwork was incomplete, lacking crucial observations during a critical time. At around 4pm on May 9, another nurse noted that baby Nalla appeared different, prompting blood tests that revealed he was hypoglycaemic and suffering from metabolic and respiratory acidosis.

By 6pm, staff discovered that baby Nalla had not been properly connected to his feeding tube for four hours. He was found lying on cold, wet sheets, and the lack of food had severely compromised his ability to fight off infection. The survival rate for sepsis in premature infants is approximately 25-30%, and baby Nalla was battling multiple conditions while being malnourished and dehydrated.

Coroner Knight described the care provided to baby Nalla as "wholly inadequate" and noted that he should have been nursed at a one-to-one ratio as per guidelines. She concluded that while there were significant failures in his care, there was insufficient evidence to legally establish neglect. The cause of death was determined to be sepsis, peritonitis, and necrotising enterocolitis.

Following the inquest, the health board is expected to implement changes to improve staffing and equipment availability in the NICU. Baby Nalla's father, in a statement read to the court, expressed the family's heartbreak over their loss and their decision to return to India after dreaming of a life in the UK. He requested that his son's body be donated to science to help prevent similar tragedies in the future.