Gloucestershire coroner calls for neonatal care probe
A coroner has called for an inquiry into the quality of neonatal care in Gloucestershire's hospitals after a 15-hour-old baby's death.
Fleur Day was delivered by Caesarean section at Cheltenham General Hospital on 9 December 2010.
The inquest found there were "missed opportunities" to save her life. A narrative verdict was recorded.
The NHS has accepted the findings and admitted its care fell below the required standards.
Fleur was born weighing 2.66kg (5lb 14oz) and was very cold.
Assistant deputy coroner Tom Osborne told Gloucestershire Coroner's Court: "She was not recognised as small for her gestational age and at high risk of hypothermia and hypoglycaemia - or that she had signs indicating she was unwell after delivery.
"These would have warranted an early paediatric review and admission to the special care baby unit for monitoring and investigation."
The "missed opportunities" to save Fleur included delays in bringing in the obstetrics registrar and consultant paediatrician to treat Mrs Day when she was first admitted as an emergency.
Mr Osborne has called on the health watchdog the Care Quality Commission (CQC) to look into the case.
A spokesman for Gloucestershire Hospitals NHS Foundation Trust said: "We accept the coroner's verdict and acknowledge that aspects of the care provided to Fleur fell below the standard that we would expect.
"We would like to offer our sincere apologies to her family for the distress caused."
The spokesman added: "We will be happy to work alongside the CQC and will further reflect on the coroner's findings within the trust and take into account any CQC recommendations to ensure our services meet the highest standards."
A post-mortem examination could not find a cause of death.