Death of baby after UK hospital missed vitamin jab ‘beyond cruel’, parents say

The parents of a boy who died at seven weeks old after a hospital failed to give him a routine injection have described the failure as “extremely cruel”.

William Moris-Patto was born in July 2020 at Addenbrooke Hospital in Cambridge, where he was incorrectly recorded as having received a vitamin K injection – which is needed for blood clotting. The injection 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 of the importance of the vitamin after a coroner concluded William would not have died if the hospital had administered the injection. On Friday, coroner Lorna Skinner QC described the omission as “a gross failure in medical care amounting to neglect”.

Naomi Moris-Patto, who heads a human embryo development research laboratory at the Francis Crick Institute, said: “Our little boy was the most precious thing to us, and we would literally do everything we could to prevent this and to him back in our arms. I can’t let that happen, but I can try to ensure that no other baby is endangered by the same negligence.”

William was born prematurely at 34 weeks on July 27, 2020 and remained in hospital for two weeks before being allowed home. Moris-Patto remembers asking in the hours after his birth 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 have a greater deficiency, the study found.

William became unwell overnight on September 11 and was taken back to Addenbrooke by ambulance. Doctors said he had suffered a brain haemorrhage and despite emergency neurosurgery he died in his parents’ arms on September 17.

“It is nothing short of devastating that we will never see William smile. We never had to buy him a crib, but 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 unwrap sloppily, no baptism to celebrate his life with our friends and family, no childcare place to find, or school uniform to buy. Because it is not just a baby we have lost, but our son at any future age, for the rest of our lives.”

A five-day inquest in Huntington, Cambridgeshire, found that William had not been given vitamin K after birth but was wrongly recorded as having done so. He died from vitamin K deficiency haemorrhage, or VKDB, which occurs in up to 1.7% of babies who don’t get 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 link 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 spontaneous intracranial haemorrhage. His death was caused by neglect, in that he had not been given vitamin K after birth and if he had been, he would not have died.”

Moris-Patto told the inquest: “It is extremely cruel that our son died, but even worse that it could have been prevented if he had received the vitamin K injection as he should have.”

The couple, who have a 14-month-old son named Charlie, have accused the Cambridge University Hospitals NHS Foundation Trust of ‘systematic failures’ in its IT and record-keeping systems.

Moris-Patto said: “We trust that they will care for William when he was small and premature and only in that first hour of my afterbirth care. It’s hard to imagine a more dependent person and even then they didn’t do the things that were expected of them. There has been a breach of trust, and that is what we will struggle with in the future.”

Alexander Moris-Patto, a researcher at the University of Cambridge who recently co-founded William Oak Diagnostics to detect deficits in babies, added: “What emerged for me from the research is that the systems they (the trust) have set up to try to prevent this from happening again are not satisfactory.”

He stressed the importance of the vitamin K injection, adding that around 1% of the UK population does not choose it. “We want people to know more about it, to understand how crucial 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 spokesperson for University of Cambridge Hospitals said: “The trust remains deeply saddened by William’s tragic death and would like to extend its sincere condolences and apologies to his family at this difficult time.

“The trust has thoroughly and diligently investigated the events leading to William’s death and fully accepts the findings of His Majesty’s coroner.

“Processes were and are continuously reviewed to ensure that similar mistakes cannot be made in the future. If the coroner has any concerns following further investigation, these will be addressed.”