The inquest into the death of a baby on Guernsey's maternity ward has found that a failing in hospital treatment contributed to his death.
Jack Tually died in January 2014 at 14 hours old, but his death only came to light in September that year after a whistleblower raised concerns over his care and the quality of services on the Loveridge Ward.
After four days of the inquest at Guernsey's Magistrate's Court, the Judge found that Jack had a relatively rare life threatening circulation condition called Persistent Pulmonary Hypertension of the Newborn (PPHN).
The inquest highlighted that the cause of this condition was not known, or when it developed, but his condition deteriorated at 6:15am.
However, the treatment given was unsuccessful as there was a leak in the intubation, which was not replaced until 9:40am.
It was considered that this length of time contributed to baby Jack's death.
Baby Jack's death was contributed to by the lack of effective intubation in the stated period. There are no other factors that I consider on a balance of probabilities contributed to baby Jack's death.
After the hearing concluded, the President of Guernsey's Health and Social Care Committee, Deputy Heidi Soulsby, read a statement on camera, giving her condolences to the family as well as stating that the island's maternity services have improved as a result of this case.