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Three-day inquest into the death of a baby who was born prematurely and suffered a perforation of an oesophageal pouch (having developed a trachea-oesophageal fistula) during the insertion of a NG tube.

The perforation was repaired but he died in circumstances that were unclear. Issues: (i) his antenatal care, specifically whether the trachea-oesophageal fistula could have been diagnosed antenatally; (ii) an overview of the care provided at hospital (including, intubation, perforation of oesophageal pouch and the repair surgery); (iii) his cause of death; and (iv) whether a Prevention of Future Deaths report was required. Experts involved: Neonatology, Paediatrics and Interventional Radiology (including from GOSH). The Coroner concluded that the thoracic duct had been damaged during the repair surgery which caused lymphatic fluid to leak into the space between the lungs and chest wall causing his death. See media (Mirror and Somerset Live)