A four week old baby, Lakshith Guptha Nalla, died in circumstances that the coroner described as deeply distressing and avoidable. His parents, who had travelled from India to Cardiff, Wales, hoping to build a better life, left Wales carrying only grief after losing their newborn son on 11 May 2024.
An inquest at Pontypridd Coroners Court, released on 4 December 2025, has now laid out exactly how a series of simple but crucial lapses in care led to this tragedy.
On 9 May, nurses removed Lakshith’s feeding tube so his parents could hold him. What should have been a warm, intimate moment became the beginning of a deadly chain of events. The unit did not have a spare tube ready, so he went more than an hour and a half without one. When a replacement was finally fitted, it was not connected properly. No one noticed.
Lakshith received no nutrition for several hours. He lay on cold and damp bedsheets, unnoticed and increasingly fragile. At the inquest, staff shared how overwhelmed they were. They were caring for far more babies than they safely could, and important checks slipped through the cracks. What should have been routine care turned into a silent emergency.
The inquest revealed gaps in his records, including a missing hour of observations between 4 pm and 5 pm. That missing hour might have been a time when his deterioration could have been recognised.
By the time nurses realised Lakshith had not been fed for four hours, his body was already struggling. Tests showed dangerously low blood sugar and signs of severe metabolic distress. He was cold, dehydrated and fighting for his life.
Coroner Rachel Knight said the care provided was not enough to protect a vulnerable premature baby. While the medical conditions that caused his death, including necrotising enterocolitis, cannot always be prevented, the lack of feeding and monitoring left him with far fewer chances to survive.
Lakshith’s parents faced the unimaginable. In the middle of their grief, they made a generous and selfless choice. They donated their baby’s body to science, hoping that what happened to him might help doctors learn and protect other newborns in the future. Shortly after, they returned to India with heavy hearts.
The hospital said it has since taken steps to fix the problems exposed by the case. Staffing levels have been increased and equipment shortages addressed. New checks and systems are now in place to prevent similar oversights.
(Rh/ARC/MSM)