A hospital's 'gross failures' which caused death of baby Julia

He is also considering calling in the police to investigate possible perjury after hearing what he called "evasiveness" from professional witnesses at the Sheffield inquest.

Six-month-old Julia Gujdanoca died just over three hours after being transferred from intensive care to a regular ward to make way for new patients because of a bed shortage.

The baby girl, who suffered a heart attack, was stable in the intensive care unit of Sheffield Children's Hospital before she was transferred to a normal ward in the middle of the night.

Nurses on the S1 ward begged doctors to readmit the sick baby to intensive care with the senior nurse Bethany West saying: "I have never seen a child cry like that before."

But it was three and a half hours before the child was moved back and she died after suffering a cardiac arrest in the lift on the way to intensive care.

Assistant deputy coroner David Urpeth blamed doctors and not the nurses on S1, saying: Having considered the whole of the evidence I am entirely satisfied these failures amount to a gross failure to provide basic medical attention."

He said the transfer was "wholly inappropriate", information about the baby's condition was not passed to nurses and doctors failed to respond to the "obvious and significant distress" of Julia by providing timely medical intervention.

He said: "There was a clear causal link between the gross failures and Julia's death."

The coroner absolved the S1 nurses of blame and instead said he was "disappointed" by the reluctance of some witnesses to be "as helpful as they could."

In particular he singled out consultant Dr Anton Mayer whom he said had told less senior colleague Dr Faith Harries to tell the inquest the baby was stable and that the transfer was appropriate.

The coroner was in a meeting with the hospital's chief executive this afternoon and will decide whether to call in the police He said: "It is a matter I need to consider."

Julia's parents are now taking legal advice with a view to suing the hospital trust.

During the inquest the hospital's nursing director John Reid was asked by Mr Urpeth if it was his view that Julia did not receive "timely" medical attention.

He replied: "That would appear to be the case."

Nurse West filed a report to hospital bosses stating she felt "unsupported by the medical team" and that Julia was an "unsuitable patient for their ward."

Julia had been ill with an undiagnosed syndrome since she was born prematurely by Caesarian section on April 9, 2009.

She had been treated at Rotherham District Hospital since her birth but was transferred to the Children's for specialist care in September.

Her father Peter Nistor told the hearing: "I believe that if she had stayed at Rotherham she would still be alive today."

Julia was in a cubicle in intensive care which was " very busy" on the night of October 21, 2009.

Two other children were due and space had to be made for them. Another baby was set to be transferred but deteriorated so a decision was made to move Julia to S1 ward.

Nurses were told she was stable and due to be taken back to Rotherham Hospital in the morning but she became distressed.

Nurse West noticed the tot was unsettled and she began crying intensely. "It was such a tiring cry I feared she would crash," she told the inquest.

She requested help at 3am from intensive care but nobody came until 3.30am when the on-duty registrar Dr Lesley Peers arrived after Nurse West made a phone call.

The nurses told the doctor to return the baby to intensive care but the registrar said her needs were more of a "nursing issue."

Sarah Marks, another nurse on S1 told the hearing: "I felt useless. I felt she didn't believe what we were doing and felt she didn't trust us. It was quite demoralising really."

Dr Peers was asked by the coroner whether the decision to transfer the baby to the ward had been the right one.

She said it was not her decision but added:"I think if nursing staff had felt they were unable to manage these episodes then she should have stayed on the Paediatric Critical Care Unit."

She said the death would not have occurred when it did if the baby had remained in intensive care.

Dr Harries, who looked after the baby in intensive care, admitted the baby did not receive the right level of care and she thought her distress could have caused the cardiac arrest.

But she said: "I think we did the best for her with the resources that were available."

Senior consultant in charge Dr Meyer said the transfer was appropriate and ICU Sister Jane Credland believed the same. "I make decisions like that every day at work," she said. "We make the best decision we can."

An internal report by the hospital trust afterwards concluded that staff on S1 "experienced difficulty" in obtaining assistance on the night. There was a bed shortage in intensive care and 20% of the staff were off sick.

Management admitted the handover from intensive care to the ward was "inadequate" and they have now improved paediatric care transfer and ensure better medical cover at night.

Julia's cause of death was given as "undiagnosed syndrome of genetic origin". She also had the MRSA superbug.

After the hearing, Julia's mother Eva Gujdanoca, 28, and her husband Peter Nistor, who also have a four-year-old daughter Emilia, of Eastwood, Rotherham were happy at the outcome.

Mr Nistor, 29, said: "I am waiting for a copy of the verdict and will then take legal advice.

"The doctors could have done more to help her. I thought it was a good hospital and had even seen it featured on television in Slovakia.

"Julia was nearly seven months. We sometimes used to stay with her overnight at the hospital. This is not the end for us."

Verdict: Natural causes contributed to by neglect.