Coroner makes recommendations to Health Department
An inquest into the death of a nine-month-old baby has found that a failure by Health Department staff to follow standard procedures "amounted to neglect".
Coroner of Inquests John Needham reconvened proceedings at Douglas Courthouse last week.
Mr Needham stated at the outset that he did not see evidence supporting any suggestion of unlawful killing here - but did wish to investigate how the baby came by his death.
The nine-month-old boy from Braddan was found to have died from gastrointestinal and respiratory failure, arising as a result of severe perinatal asphyxia, or lack of oxygen to the brain.
It's thought this damage was sustained during complications at childbirth, where there was a 40 minute gap after the birth of his twin sibling.
Mr Needham's verdict found that "repeated opportunities were missed to expedite the delivery of the twins", that a consultant obstetrician was not present at delivery, which is required by guidelines, and that "individual and systemic failures amounted to neglect".
The Coroner made a list of recommendations to the Health Department, in an attempt to ensure such a case does not happen again.
He also added that the case should not be forgotten or displaced because of shrinking budgets, cost cutting measures or the replacement of staff.