A couple from Sheffield wept as a coroner told them their premature baby died because of failings in his care.
Karolina and James Curry were at the final day of an inquest into the death of their son, Cassian, who lost his life at two days old.
Assistant coroner Abigail Combes concluded that a failure to record and share information about Cassian's care on the Jessop Wing in Sheffield contributed to his death.
The inquest had previously heard how an umbilical venous catheter (UVC) was inserted in a "sub-optimal" position in Cassian's abdomen near his heart by two junior doctors after he was born at 28 weeks on 3 April last year, weighing less than 2lbs.
The error was identified and neonatal consultant Dr Elizabeth Pilling told the inquest she intended to have the line repositioned within 24 hours but waited because of the dangers of repeatedly handling a very premature baby. She then forgot to take action.
Cassian suffered a cardiac tamponade, a process where fluid builds up in the space around the heart, preventing it from pumping. He died on 5 April.
Giving her conclusion, Ms Combes said the decision to pause the procedure and reassess it in 24 hours was "reasonable and appropriate", but was "not adequately recorded and communicated" in Cassian's notes, or on the ward round.
She noted that the plan should have been recorded on Cassian's "pink sheet," and communicated to his parents.
Ms Combes said that this amounted to a "gross failure" in Cassian's care, and one which contributed to his death.
She added: "But for this incident, Cassian would not have died of what he died of, when he died."
The coroner recorded a narrative conclusion, which said Cassian's death was "contributed to by neglect".
But the inquest heard the unit was properly staffed, according to national guidelines and there were no absences.
The Sheffield Teaching Hospitals NHS Foundation Trust, has already apologised over Cassian's death admitting there was "human error" in his treatment.
The Care Quality Commission (CQC) has raised concerns about maternity services at the Jessop Wing and rated them as inadequate a month before Cassian was born, confirming this judgment earlier this month.
But the NHS trust has stressed that the neonatal unit did not form part of these maternity inspections and judgments.