Baby died in breathing tube swap, inquest hears

A premature baby died after hospital staff tried to change his breathing tubes, an inquest has heard.

Teddy Martin - who was born at 32 weeks - was 35 days old when he suffered a cardiac arrest at Nottingham's Queen's Medical Centre on 5 September 2023.

During the inquest in the city, assistant coroner Elizabeth Didcock read out statements from parents Ellie Clougherty and Ainsley Martin complaining of a lack of consultation about the procedure and difficulty getting a report into the death.

The doctor who was involved in the procedure said he was not aware of all previous problems with Teddy's breathing.

Teddy was born with a genetic condition that gave him an enlarged tongue.

While on the high dependency unit of the QMC's neonatal department, he was kept on ventilation to aid breathing.

The inquest heard this was twice removed but both times were unsuccessful with Teddy having to be resuscitated.

While Teddy was stable, concern over secretions blocking his oral breathing tube led to the decision to replace it with a nasal version.

In a statement, Ms Clougherty said they had specifically requested to be present if any changes were made but in the event, they were away when the procedure began and had to be called back when problems arose.

She said: "The team had told us changing to a nasal tube was being considered but we had no idea it was going to be done.

"We couldn't understand how he had gone from stable to dead in a few hours."

Mr Martin's statement said: "If we knew, we would have made sure we were present but we were made to feel as if we were being a nuisance by asking too many questions.

"We were left feeling overwhelmed and confused by what had happened."

Giving evidence, Dr Matthew Fox, who attempted the tube change, said he was not aware of all the difficulties Teddy had previously experienced.

In previous resuscitations Teddy had not responded to manual ventilation and when the nasal tube was knocked out as the oral tube was withdrawn, manual ventilation was attempted for several minutes.

He said: "With the knowledge we had at the time, the decisions we made were safe and appropriate.

"But if we had known the challenges Teddy had with face mask ventilation, other safety measures would have been in place."

The family also said they had to wait months for an internal report into what had happened, eventually enlisting the help of Donna Ockenden, head of the inquiry into maternity failings at the trust, to have it handed over.

The inquest is due to last another four days.

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