A TWO-month-old baby died at Derriford Hospital after "bad failings" among staff, an inquest heard.

Ethan Cross's brain was fatally starved of oxygen when a breathing tube which had probably become dislodged was replaced too slowly, the hearing was told.

He died due to the injury a week later, on November 14, 2009.

His mother Shelley Cross, aged 29, of North Prospect, attended the inquest yesterday.

Andrew Cox, deputy coroner for Plymouth, recorded a verdict of death by misadventure.

He said: "In my view there were failings, bad failings even. There was not, however, a total and complete failure."

Describing the events that led to Ethan's tragic death, Mr Cox said "individually competent people failed collectively in this critical situation".

He noted a lack of experience and confidence in a new doctor expected to take charge of the emergency.

An in-depth investigation was carried out by the hospital following the incident. It lead to changes around training, reviewing new doctors, team working and management of ill babies.

Ethan was born on September 7, 2009. The birth took place at a specialist hospital in Bristol because some of his organs were growing outside his body.

He underwent a successful operation to correct the life-threatening condition when he was just a couple of days old.

The inquest heard Ethan had suffered a number of incidents where his blood oxygen and heartbeat fluctuated while in Bristol.

However, as he had been improving and his condition was considered no longer life-threatening, he was transferred to Derriford Hospital on November 6 on a ventilator.

Staff in the neonatal intensive care unit that night included an experienced staff nurse who was tasked with giving Ethan one-to-one care, and a ward sister who had worked on the unit for 10 years.

There was also two new doctors, a specialist registrar in charge of the ward and a senior house officer. Both had worked in the neonatal unit for about two months. There was also a consultant on call.

Dr Cox said the "critical event" happened at around 4am on November 7.

He said the "likely trigger" was his breathing tube becoming displaced from his windpipe into his oesophagus.

Mr Cox described staff's initial response as "appropriate", including Ethan being given oxygen and increased ventilation. He said that the consultant, who was telephoned at about 4.15am, was called at the right time and responded appropriately.

However, before the consultant arrived, the emergency needed "confident clear leadership", which the registrar was expected to provide and did not do so, the coroner said.

He said staff had relied too heavily on listening to Ethan's chest to check whether the tube was in place. An expert witnesses had described the method as "notoriously difficult".

Mr Cox said the registrar's actions were those of a doctor with "little experience" of the specialist skills required, and "lacking confidence" to lead in an emergency.

The tube was finally removed on the advice of the consultant, who was on his phone en route to the hospital. He arrived shortly afterwards and replaced it but by that time the damage was done.

Robert Antrobus, partner and head of clinical negligence at Foot Anstey, who represented the family during the inquest, said: "The family are grateful to the coroner for his thorough review of the events leading up to Ethan's death.

"Sadly the coroner, delivering a verdict of misadventure, has found evidence of substandard care which has played a significant part in baby Ethan's death.

"The family does however acknowledge that the Trust have undertaken a full investigation which highlighted problems with Ethan's care through its serious untoward incidents (SUI) procedure. Indeed, it is reassuring to note that the trust has identified steps to take, and improvements to be made, following Ethan's death. The family sincerely hope that the lessons learned in this tragic case result in other families not having to go through what they did."

Plymouth Hospitals NHS Trust yesterday released a statement detailing "robust" changes made following the death.

A spokesman said: "We 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."