A North East hospital trust has been told that they "more likely than not" contributed to the death of a newborn baby, after failing to administer antibiotics. 

Alfie Neil Mains-Forster was born on June 13, 2022, but died only a day later. 

His medical cause of death was determined to be severe congenital pneumonia and meningitis, as well as suspected acute chorioamnionitis. 

But the assistant coroner for County Durham and Darlington, Crispin Oliver, determined that staff failure to administer antibiotics likely contributed to the tragedy in Durham's A&E unit.

The Northern Echo: Lib - A general picture of the exterior of the RVI - Royal Victoria Infirmary, Newcastle

Alfie was born a week late in the early hours of June 13, 2022, at the Royal Victoria Infirmary, Newcastle Upon Tyne.

His mother had risk factors – gestational diabetes, a congenital heart condition and heightened blood pressure. 

Within four minutes of his birth, Alfie was noticed to be "grunting". 

Around two hours later, Alfie's condition was noted in his chart, with two observations - respiration rate and oxygen saturation - ranked in the amber category. 

NHS framework states that a baby with two or more amber scores should have their care immediately escalated to the pediatric team, with the expectation that the patient is reviewed within half an hour.

Cyanosis - a bluish skin colour, related to decreased amounts of oxygen - was noticed by medical staff around Alfie's mouth and nose.

As a result of these observations and intermittent grunting, Alfie's mum was concerned. 

A medical review, that occurred around 4.30 am, noted that oxygen saturation was on the increase, up from 88 per cent to 89.93 per cent, and then 97 per cent at retesting. 

No other signs of respiratory distress were noted at this time. 

The evidence from Newcastle Hospitals NHS Foundation Trust included that given the maternal risk factors, once the two amber category observations had been documented, antibiotics should immediately have been administered to Alfie on a pre-emptive basis. 

However, antibiotics were not administered, and Alfie was not closely monitored. 

He was discharged at around 16.45 pm, where he became "increasingly unsettled, crying consistently," worsening to the point that his parents phoned 999. 

Alfie died in University Hospital of North Durham in the early hours of the next morning. 

Coroner Crispin Oliver concluded: "The omission of antibiotics from 03.55 on 13 June 2022 is more likely than not to have contributed directly to Alfie’s death and, but for this omission, he would not have died."

He added: "During the course of the investigation my inquiries revealed matters giving rise to concern.

"In my opinion, there is a risk that future deaths could occur unless action is taken. In the circumstances, it is my statutory duty to report to you."

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He noted that improvements could be made the the electronic system used at the RVI, as it currently "does not map the national guidance fully". 

A medical chart - NEWTT2 - is also currently not available on the electronic system. 

He said: "This was supposed to be implemented in July 2023 but as yet it has not."