The parents of a premature baby have called for answers over whether staffing issues at a neonatal unit over a bank holiday contributed to their son's death.
Cassian Curry died two days after he was born at Sheffield Teaching Hospitals' Jessop Wing maternity unit on 3 April 2021, a coroner said on Tuesday.
He weighed 1lb 10oz (750g) when he was born at 28 weeks.
In a statement read to the hearing in Sheffield, Cassian's mother, Karolina Curry, said she and her husband, James, had questions about their son's treatment.
They said they had heard reports the unit was understaffed due to it being the Easter weekend and that medics failed to act on her concerns, including about her son's raised heart rate.
Mrs Curry said: "We still can't get our heads around any of this and how a bank holiday means your child dies.
"We cannot understand why they can't have life-saving checks or the right number of staff because of a bank holiday."
Mrs Curry said her pregnancy with Cassian was "a miracle for us" as it came after six cycles of IVF, which was needed due to her husband's cancer.
She said her son was placed on total parental nutrition (TPN), which is routine for such premature babies, and doctors inserted an umbilical venous catheter (UVC) to deliver this.
The inquest will examine whether the whether the UVC had been incorrectly sited too close to Cassian's heart and also whether there was a failure to review its position and re-site it.
Mrs Curry said she twice noted that her son's heart rate increased to more than 200 beats per minute but was told by medical staff that it was nothing to worry about.
She said she also worried that Cassian had not produced any bowel movements and this was a sign that he was not feeding properly.
Mrs Curry said in her statement: "I said to James that something wasn't right. He assured me that he was in safe hands."
She said she got more and more worried but a nurse told her "It's all right, love, it's normal."
'I tried to scream but nothing came out'
Mr and Mrs Curry sat together at Sheffield's Medico-Legal Centre listening to the statement, which was read by assistant coroner Abigail Combes.
In it, Mrs Curry described her horror when she went down the intensive care unit to find doctors battling in vain to save her son.
She said: "I tried to scream but nothing came out."
She added: "I looked at the doctors and nurses and I can only describe the looks on their faces as horrified."
And she said: "I couldn't speak. I was opening my mouth but nothing was coming out. James said it was like a silent scream."
Mrs Curry, who said she is a Roman Catholic, said she was horrified that, when she asked a priest to baptise her son in hospital, he brought holy water in a sample bottle.
And she criticised the bereavement services she was offered when they were "shocked and furious" and "lost and desperate".
"We still feel the guilt today for unknowingly putting him in so much danger," she said.
Mrs Curry said: "The whole process from when Cassian was born to his death had just seemed chaotic."
The Care Quality Commission (CQC) identified significant patient safety concerns in March 2021 – a month before Cassian died – which saw the rating of the maternity services at the trust downgraded to inadequate.
Earlier this month, the inspectors announced that the trust had failed to make the required improvements to services when it visited in October and November, despite warnings.
The service did not have enough midwifery staff with the "right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment", the CQC said.
Dr Jennifer Hill. Medical Director, Sheffield Teaching Hospitals NHS Foundation Trust added: “We know that no apology will lessen the pain of Cassian’s death for his parents and family, but we are so very sorry for what happened, and we have already provided Mr and Mrs Curry with a full explanation of what happened and the changes we have made since his death.
"Whilst staffing numbers on the Neonatal Unit that weekend were appropriate and within national recommendations it was very busy and regrettably there was human error in terms of the management of Cassian’s umbilical venous catheter.
"This was a very rare incident, and everyone involved in Cassian’s care is devastated. There has been a full review of what happened, and changes have already been made to limit the chances of this happening again.”
Coroner Ms Combes said the CQC's findings will be referred to in the inquest but stressed that the two inquiries had different remits.
The inquest is expected to conclude on Friday.