‘Serious failure’ and ‘lack of proper care’ contributed to the passing of two-day-old Cassian Curry, a coroner has concluded.

Tiny Cassian, who weighed just 750 grams when he was born at 28 weeks on April 3 last year, passed away on the neo-natal unit of the Jessop Wing at Sheffield Teaching Hospitals while in intensive care. At an inquest into his passing, assistant coroner Abigail Combes ruled there was “a serious failure” by staff to hand over notes about his medical care and added: “Cassian’s passing was contributed to by a lack of proper care”.

Cassian was described as “a miracle baby” by his parents. Dad James’ cancer diagnosis meant they went through six rounds of IVF and suffered a number of miscarriages.

Cassian was born prematurely at 28 weeks but weighed just 750 grams and was the size of a typical 24-week-old baby. Despite this, nurses described him as “doing remarkably well for his age” before he passed.

At the end of a four-day inquest, Ms Combes concluded ‘serious failure’ and ‘lack of proper care’ on the neo-natal unit of the Jessop Wing in Sheffield led to the tiny baby’s passing. She ordered a review of services at the hospital and told them to issue a response within 56 days.

The inquest’s conclusion comes less than a month after Sheffield Teaching Hospitals Trust was rated inadequate following a critical CQC report. Parents have since exclusively revealed to YorkshireLive about their “distressing” experiences, which include instances of mums being left in discomfort, asking for pain relief and worried about their babies’ safety.

However, the Trust stressed the inadequate rating did not relate to the neo-natal unit. Reacting to the outcome of the inquest, Dr Jennifer Hill, medical director at Sheffield Teaching Hospitals NHS Foundation Trust, said: “We know that no apology will ever be enough to lessen the pain of Cassian’s passing for his parents and family, but we are so very sorry for what happened and have already provided Mr and Mrs Curry with a full explanation of what happened and the changes we have made since his passing.

“Whilst staffing numbers on the neo-natal Unit that weekend were appropriate and within national recommendations it was very busy and regrettably there was a genuine human error in terms of the management of Cassian’s umbilical venous catheter. This was a very rare incident to have happened and everyone involved in his care is deeply saddened.

“There has been a full review of what happened, and changes have already been made to limit the chances of this happening again including additional Consultant support at weekends and ongoing improvements to the documentation used. We will also be taking on board any further recommendations from the coroner and ensuring we respond with appropriate actions.”