Coroner to consider whether 'neglect' contributed to death of baby Cassian Curry in Sheffield

Cassian Curry and parents Karolina and James
Cassian Curry weighed less than 2lbs when he was born. Credit: Family handout

A coroner has said she is considering whether neglect contributed to the death of a premature baby in a neonatal unit.

Cassian Curry, who was born at 28 weeks weighing less than 2lbs, died in the Jessop Wing maternity unit in Sheffield two days later, on 3 April last year.

An inquest has heard how a catheter inserted into Cassian's abdomen to help him feed may have been incorrectly sited too close to his heart, and is considering whether there was a failure to review its position and re-site it.

On Tuesday, his mother Karolina told the inquest that she and her husband, James, want to know whether understaffing at the unit contributed to Cassian's death.

On Wednesday, assistant coroner Abigail Combes told lawyers representing Cassian's parents, Karolina and James Curry, and Sheffield Teaching Hospitals NHS Foundation Trust, that she will have to consider whether neglect contributed to Cassian's death as part of her proposed narrative conclusion later this week.

Ms Combes said her preliminary view was that "on the basis of the evidence I have heard" this would not necessarily relate to the initial placement of the feeding line – called an umbilical venous catheter (UVC) – but to the subsequent decision-making.

But the coroner stressed she still had to hear from key witnesses.

Earlier, neonatal doctor Mark Attard told an inquest how he was called to an emergency situation on the intensive care unit and was "very surprised" to find it was baby Cassian who was being worked on.

Doctor 'had no concerns'

Dr Attard, who is now a consultant at Aberdeen Maternity Hospital, said he was the registrar on duty overnight when Cassian died.

Asked by the coroner about his ward round about four hours before, Dr Attard said: "I had no concerns about his (Cassian's) progress.

"The opposite. I was quite happy with his progress. For a 28-weeker, I felt he was in quite a good condition."

He told the coroner: "I was very surprised to arrive in that room to find it was Cassian."

Dr Attard described how, at the end of his shift the previous night, he noticed on an X-ray how the UVC appeared to be projecting into the "cardiac shadow".

He said he pointed this out to consultant Dr Elizabeth Pilling, who had recorded it as "sub-optimal" but decided to leave it in place - a decision he said she balanced against other potential harms to Cassian after the initial insertion procedure had taken longer than normal.

Another consultant working in the unit, Dr Catherine Smith, said she had not seen the X-ray until after Cassian's death.

She said that, if she had seen the image on 3 April, she would have had a member of the team "pull it back".

But Dr Smith stressed that this was a decision that had to be balanced against other potential issues, including the dangers of further handling such a pre-term baby, and lack of nutrition while the procedure was being undertaken.

Mr and Mrs Curry have said Cassian was "a miracle for us" when they found out he was on his way after six cycles of IVF.