A coroner has ruled that a series of failings in care led to the death of 35-day-old Teddy Martin at Nottingham's Queen's Medical Centre (QMC). Teddy, born prematurely with a genetic condition causing breathing difficulties, died after a procedure to change his breathing tubes.
Teddy Martin, who was born prematurely at 32 weeks, tragically passed away at the age of 35 days in September 2023 at Nottingham's Queen's Medical Centre (QMC). During a procedure to change his breathing tubes, Teddy suffered a cardiac arrest and, despite resuscitation efforts, was unable to recover. He had been admitted to the hospital for five weeks due to a genetic condition that caused an enlarged tongue and breathing difficulties.
While on the high dependency unit, Teddy was kept on ventilation to assist his breathing. The decision to replace his oral breathing tube with a nasal one was made due to concerns about secretions blocking his airway. Assistant coroner Elizabeth Didcock acknowledged that the procedure was appropriate, but she pointed out a critical lack of contingency planning. The nasal tube dislodged accidentally, and Teddy's airway became obstructed as a result of his genetic condition. The coroner concluded at Nottingham Coroner's Court that a series of failings led to Teddy's rapid deterioration after the procedure. She criticized the inadequate rescue plan in case re-intubation failed and highlighted the lack of documentation and planning before the procedure. The coroner also stated that it was unlikely the risk assessment was communicated to Teddy's parents. In a statement read outside Nottingham Council House, Teddy's family expressed their profound heartbreak over the loss of their son, emphasizing that they fought tirelessly to understand the reasons behind his death. They revealed that they finally received an internal report after months of waiting, and even sought the assistance of Dr. Donna Ockenden to investigate. Nottingham University Hospitals NHS Trust (NUH) issued a statement expressing sincere condolences to Teddy's family. They fully accepted the coroner's findings and apologized for the care provided on the day of Teddy's death, stating that it did not meet the standards expected and deserved by his family. The trust confirmed that they had discussed their review with Teddy's family and that changes had already been implemented. These changes include the appointment of a new neonatal airway lead, improvements to the intubation checklist, and a review of ventilation guidance with ward colleagues. They also mentioned changes aimed at supporting learning through investigations
Baby Death Hospital Failure Nottingham QMC Coroner's Inquest Neonatal Care
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