Coroner rules that premature baby “would have survived” with better hospital care

The inquest into the death of Teddy Martin has taken place in Nottingham and concluded that Teddy’s death at only 35 days old could have been prevented.

Teddy was born prematurely, at 31 weeks, suffering from a genetic condition which resulted in him having a larger than average tongue. This condition, known as Beckwith-Wiedermann Syndrome, resulted in breathing difficulties. Teddy was being treated in the high-dependency unit of the Nottingham Queen’s Medical Centre and was initially ventilated by oral intubation.

A decision was then made to change this to nasal intubation, which should have been safer for him. However, during the changeover process, the nasal tube was accidentally dislodged, and Teddy’s airway became blocked by his tongue. An attempt to rely on facemask ventilation failed, and Teddy deteriorated rapidly, suffering cardiac arrest. Significant attempts were made to resuscitate him, but these were unsuccessful, and he died on 5 September 2023. The Coroner found that the team in charge of Teddy’s care failed to complete an adequate risk assessment prior to undertaking the tube change, and safety measures which may have saved Teddy were not taken.

The Nottingham University NHS Trust conducted a Patient Safety Investigation following Teddy’s death. However, during the inquest, the Coroner criticised the investigation, describing it as a “disaster” and criticised the Trust’s lack of communication with the family. The Trust has now admitted liability for Teddy’s death.

The family’s solicitor is Bethany Kyle of Ashtons Legal. She comments: “Teddy’s family were heartbroken by his tragic loss. They fought tirelessly to understand why he died and, following the Coroner’s conclusions, now know it was due to avoidable failures in his care”.

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