The parents of a baby boy who died at seven weeks old after a hospital did not give him a routine injection have described the failure as “beyond cruel”.
William Moris-Patto was born in July 2020 at Addenbrooke’s hospital in Cambridge, where it was recorded in error that he had received a vitamin K injection – which is needed for blood clotting. The shot is routinely given to newborns to prevent a deficiency that can lead to bleeding.
His parents, Naomi and Alexander Moris-Patto, 33-year-old scientists from Chatteris, Cambridgeshire, want to raise awareness about the importance of the vitamin after a coroner concluded William would not have died had the hospital administered the injection. On Friday, the coroner Lorna Skinner KC described the omission as “a gross failure in medical care amounting to neglect”.
Naomi Moris-Patto, who leads a research lab on human embryo development at the Francis Crick Institute, said: “Our little boy was the most precious thing to us, and we would do literally anything to have prevented this from happening and to have him back in our arms again. I can’t make that happen, but I can try to make sure that no other baby is put at risk because of the same omissions.”
William was born premature at 34 weeks on 27 July 2020 and remained in hospital for two weeks before being allowed home. In the hours after his birth, Moris-Patto remembers asking if he had received the vitamin K shot and was reassured that he had. All babies are born with a vitamin K deficiency, but premature babies are more deficient, the inquest heard.
William became unwell overnight on 11 September and was taken back to Addenbrooke’s by ambulance. Doctors said he had suffered a brain haemorrhage and despite undergoing emergency neurosurgery, he died in his parents’ arms on 17 September.
“It is nothing short of devastating that we will never get to see William smile. We never got to buy a cot for him, instead we had to pick out a coffin,” Moris-Patto said.
“His first birthday has come and gone, just as Christmas and Easter have come and gone, without him. No presents for a chubby toddler to messily unwrap, no christening to celebrate his life with our friends and family, no nursery placement to find, or school uniform to buy. Because it is not just a baby that we’ve lost, but our son at every age to come, for the rest of our lives.”
A five-day inquest in Huntington, Cambridgeshire, heard that William had not been given vitamin K after birth, but that it had been recorded in error that he had. He died of vitamin K deficiency bleeding, or VKDB, which occurs in up to 1.7% of babies who do not receive the shot at birth, according to the National Childbirth Trust.
The coroner said: “The failure to administer vitamin K was a gross failure in medical care amounting to neglect. There is a clear and direct causal connection between that failure and William’s death in that if he had been given vitamin K, he would not have died.”
In a narrative conclusion, she added: “William died of natural causes – a vitamin K deficiency, which caused a spontaneous intracranial haemorrhage. His death was contributed to by neglect in that he was not given vitamin K after birth and if he had been, he would not have died.”
Moris-Patto told the inquest: “It is beyond cruel that our son died, but even worse that it could have been prevented, had he been given his vitamin K injection as he should have been.”
The couple, who have a 14-month-old son called Charlie, have accused Cambridge University hospitals NHS foundation trust of “systematic failures” in its IT and record-keeping systems.
Moris-Patto said: “We put our trust in them to look after William when he was tiny and premature and on his own in that first hour when I was having my after-birth care. It’s hard to imagine a more dependent person and even then they didn’t do the things they would have been expected to do. There is a betrayal of trust, and that’s what we’ll find hard in the future going forward”
Alexander Moris-Patto, a researcher at the University of Cambridge who recently co-founded William Oak Diagnostics to test for deficiencies in babies, added: “What’s come out of the inquest for me is that the systems they [the trust] put in place to try to prevent this happening again are not satisfactory.”
He stressed the importance of the vitamin K injection, adding that about 1% of the UK population opt out of it. “We want people to know more about it, to understand how critical it can be, and for hospitals to take seriously the responsibility they have in those first precious hours of a baby’s life,” he said.
A Cambridge University hospitals spokesperson said: “The trust remains deeply saddened by William’s tragic death and wishes to express its sincere condolences and apologies to his family at this difficult time.
“The trust thoroughly and diligently investigated the events leading up to William’s death, and fully accepts the findings of His Majesty’s coroner.
“Processes were, and continue to be, constantly reviewed to ensure a similar error cannot be made in the future. If, following further review, the coroner has any concerns, these will be addressed.”
