A four-week-old baby has died after being left for several hours lying on cold and wet bedsheets in a critically understaffed neonatal intensive care unit. Lakshith Guptha Nalla was malnourished and dehydrated when he passed away in the “care” of the NICU at the University Hospital of Wales in Cardiff.

An inquest at Pontypridd Coroners’ Court heard how Lakshith died in the early hours of May 11, 2024, a day that has changed his parents’ lives “forever”, according to Wales Online. Coroner Rachel Knight told the court how a series of failures due to “persistent and gross understaffing” led to the four-month-old being left with food for four hours, with no staff noticing he developed an infection while lying in cold, wet bedding.

Laskhith was said to be “entirely dependent on the NICU” with one example coming two days earlier, when nurse Pasqualina Mollo, in charge of the child’s care, disconnected his feeding tube to allow for his parents to have a cuddle with him – despite needing constant feed.

The nurses then noticed that the ward was without new feeding lines due to a “chaotic” stocking system. The team eventually managed to source six more tubes from another ward.

Ms Knight added: “I find it surprising that feeding tubes were not available on the biggest neonatal ward in Wales.”

An hour and a half later, Nurse Mollo managed to fit the new tubes onto the ill four-month-old but failed to fit them properly as she was “in a rush” before being called to deliver another baby.

She also failed to inform anyone of the food missed or conduct any blood tests to see how the child had been affected.

The inquest heard how understaffed and overstretched the nurses on the unit were, with the hospital demanding that they look after twice the number of patients than a correctly staffed NICU would call for, with “the staff on the ward were asked to do too many jobs during their shift”.

On top of that, a routine observation was missed between 4pm and 5pm. Another nurse noticed that the baby’s condition looked to have changed at 4pm when tests were taken that revealed that Lakshith was hypoglycaemic, and was suffering from metabolic and respiratory acidosis.

At 6pm, nurses noticed that his feeding tube had been leaking and that his bed sheets were cold and wet.

The court heard how premature babies with sepsis have a survival rate of only 25-30% and Lakshith was fighting two more conditions, all while being cold, dehydrated and malnourished.

Ms Knight described baby Nalla’s care as “wholly inadequate”, and the mistakes leading up to his death were an “unfortunate coincidence”, and added that the issue of neglect could not be legally made out by a very narrow margin.

Giving the official cause of death, Lakshith was found to have died from sepsis, peritonitis, and necrotising enterocolitis, with no evidence found to say that the food as prescribed could save the baby.

The coroner ruled that they came to a narrative conclusion for his death, stating: “Baby Nalla was born at 30 weeks and four days gestation with a congenital condition that required surgery. This surgery was undertaken the day after he was born, and he was making a full recovery.

“Baby Nalla should have been nursed at a one-to-one ratio as per the guidelines. Due to staffing levels on the ward and missing equipment, he was not nursed to the standard he should have been and was not fed at all for four hours.

“He was showing signs of necrotising enterocolitis, which is likely his cause of death. There is insufficient evidence that the complications surrounding baby Nalla’s feed contributed to his death.”

Since the incident, the health board has made changes to stocking and staffing at the NICU, which was said to have satisfied the coroner.

The court heard from Lakshith’s dad, who said they had moved to Cardiff to pursue a dream, but since the death of their child, had moved back to India.