Inquest into the death of Baby Teddy Joseph Martin at Nottingham Coroner’s Court

The Inquest into the death of Baby Teddy Joseph Martin is to take place at Nottingham Coroner’s Court, The Council House, Old Market Square, Nottingham NG1 2DT, 6–10 January 2025 at 10am.

Teddy Martin, the second baby of Ellie Clougherty and Ainsley Martin, was born on 2nd August 2023 at 31+1 weeks, weighing 2.29kg. He was admitted to NICU at Queens Medical Centre, Nottingham, but sadly died avoidably at the age of 35 days during a re-intubation procedure. Teddy was suspected to have Beckwith Wiedemann Syndrome (BWS), a rare genetic disorder which causes a large tongue. This diagnosis was confirmed the day after he died.

During his time in the NICU, there were a series of failed extubations, following which Teddy had to be resuscitated and re-intubated. An ENT procedure on 31 August 2023 confirmed that Teddy had a “difficult airway” due to his large tongue and that this had contributed to the difficulty in taking him off ventilation. Despite these difficulties, Teddy was stable and expected to be discharged home following his due date to await tongue reduction surgery.

On 5 September 2023, Teddy underwent a change of his oral endotracheal tube to a nasal endotracheal tube. Despite Teddy’s history and difficult airway, the procedure was performed by a junior doctor who had never carried out a nasal intubation on a neonate before. There was insufficient planning for the procedure, and Teddy’s medical conditions were not properly considered. Sadly, the procedure went wrong, with catastrophic consequences. Teddy deteriorated quickly and resuscitation attempts failed.

Teddy’s family say that they were not properly consulted about the tube change and had specifically requested to be present for all planned procedures taking place in light of the difficulties that were encountered when extubating Teddy in the past. The extubation/tube change took place whilst both Teddy’s parents were away from the hospital with their older son. By the time they were called into the hospital, they were told resuscitation attempts had been ongoing for too long and were now futile.

Trust conduct

Following Teddy’s death, the Trust commissioned a Patient Safety Incident Investigation (PSII). This report was critical of the care provided to Teddy and set out a detailed action plan to avoid further deaths occurring in the future. The family were not provided with the report until July 2024, almost 11 months after Teddy’s death. The report was only produced following intervention from Donna Ockenden, who leads the maternity review into the Trust.

Even once Teddy’s parents had been provided with the report, on the eve of a Coroners hearing, despite the report being published, the Trust continued to dispute its findings, changing their position on several occasions. All of which came before the Coroner in preliminary hearings where the Trust sought to utilise the inquest process to settle conflicts of political views of Trust clinicians. Ultimately leading to those clinicians being individually represented at Inquest, the Trust, at expense instructing Kings Counsel, and yet still denying any wrongdoing.

Following extensive disclosure requests by the Coroner, the reality was that the Trust had commissioned its own independent report, which confirmed that the sad death of Teddy was wholly avoidable.

Such disclosure spans thousands of pages, which a bereaved family have had to grapple with, and has evidenced very concerning commentary regarding how the Trust should manage themselves at the inquest, how patient safety and the duty of candour is balanced with avoiding scrutiny for what is clearly an avoidable death of a baby.

The Trust has now accepted liability for Teddy’s death and admitted that it was avoidable. However, individual clinicians who treated Teddy continue to deny any wrongdoing and will not agree with the position set out in the PSII or the Trust’s admission of liability. As a result, these individuals will be individually represented at the upcoming inquest.

Teddy’s parents have fought tirelessly to find out why their son died. They hope that the inquest will provide them with the answers they need. However, due to the Trust’s recent admission of liability, there is a high risk they will be required to pay for the costs of their legal representation themselves, which otherwise would have been recoverable from the Trust. The Trust has been asked to provide assurances that the family will not have to pay the huge cost of representation, but these requests have been denied, with the Trust’s legal representatives stating that they should be required to use damages awarded to Teddy’s estate to cover the cost of the representation. Notably, the Trust has instructed a hugely experienced Kings Counsel to represent them at the inquest.
The family are grateful to the Coroner for her full and fearless investigation into Teddy’s death. They are also grateful to Donna Ockenden, who has provided them with a huge amount of support and assistance.

Legal representation

The family is represented by Medical Negligence solicitor and birth injury claims specialist, Bethany Kyle from Ashtons Legal, who is advising them in relation to the inquest and a civil claim against the hospital. They hope that the inquest will reveal exactly what happened in the lead-up to Teddy’s death. It will be the first time that they will hear directly from key individuals responsible for Teddy’s care.

Bethany states:

“Teddy’s tragic death was caused by a lack of consideration for his individual needs. The staff treating Teddy on the day he died had unfounded confidence in their actions and made reckless decisions that cost Teddy his life. Even now, the Trust and their staff continue to act in a way which causes Teddy’s family needless harm. I hope that following the inquest, they will take meaningful steps to avoid a similar incident, and to avoid conducting themselves in a way that serves to compound the pain of grieving families.”

Press enquiries

For all press enquiries relating to the inquest, interview availability, or for more information on the family’s story, please contact Bethany Kyle on bethany.kyle@ashtonslegal.co.uk or Natalie Cosgrove on natalie.cosgrove@ashtonslegal.co.uk in the first instance.

A statement will be given following the end of the inquest to be read out to press present.