A spokesperson for Plymouth Hospitals NHS Trust, said: “We would like to offer our sincere sympathies to the parents and family of baby Ethan.

“This was a very sad case and we are extremely sorry that there were failings in the care given to Ethan.

“As the Coroner noted during the inquest, we had undertaken a full investigation into what happened and, as a result, we have made a series of robust changes within our Neonatal Intensive Care Unit during the past year.

“We have
• Introduced carbon dioxide monitoring as a standard part of care for ventilated infants – these sensors detect exhaled waste gases which can give early warning of a displaced breathing tube.
• Put in place measures to ensure that all staff undertake and update their Newborn Life Support training and accreditation.
• Put in place multi-professional emergency scenario training using a new simulation mannequin within a dedicated resuscitation training area. This training starts at induction when any new member of medical staff joins the neonatal team. This helps to develop better emergency team working and leadership skills.
• Introduced a tool, which in addition to the standard assessment of medical staff in training, allows us to better share information about their competencies and/or their support needs.
• Developed better documentation which shows the presence of the senior medical and nursing leads at all ward rounds and handovers.

“We will, of course, consider the Coroner’s full findings and look to see whether any further changes are needed.”