The tragic death of Ethan Verrin – at only one day old – could have been avoided if hospital staff had heeded the concerns of his parents, an inquest has heard.

Samantha and Dale Verrin treasure the memory of the short time they spent with their son, but the couple are struggling to come to terms with the fact the infection that killed him, though easily treatable, was missed by doctors and midwives.

An inquest this week heard Mrs Verrin, 32, who has two older children, had raised several concerns following Ethan’s birth at Medway Maritime Hospital in the early hours of Friday, December 5, last year.

But she was assured her baby was okay and allowed to go home to Montgomery Avenue, Chatham, later that day.

The fact he had not appeared to feed; had remained mostly asleep; bubbles had appeared around his mouth, and every breath he took seemed to be accompanied by an unusual sound, were just some concerns which might have been picked up as a sign of infection by experts, while his temperature was also slightly higher than normal.

Nevertheless coroner Patricia Harding recorded a verdict of death by natural causes after hearing that the signs of infection were subtle, and staff could not necessarily have been expected to detect them.

Gill Marchant, the last midwife to assess Mrs Verrin, was questioned by Mrs Harding, and said she hadn’t heard Ethan make “grunting” noises which neonatal care workers are taught to look out for as signs of infection, and didn’t notice bubbles or mucus around his mouth.

She had put the temperature down to the fact that he was wrapped in a thick blanket, and said Ethan had briefly woken and cried – although this was queried by the coroner who noticed there was no mention of Ethan crying in her original statement.

“I just recollect holding the baby,” said Mrs Marchant. “I won’t say he was crying for five minutes. He just had a bit of a cry when he woke up.”

Under cross-examination she admitted: “It would have been appropriate to take the temperature again.

“There were lots of other things going on.

“I hold my hands up – I should have checked the temperature and I didn’t.”

Other midwives and Dr Ankit Khanna, a paediatric doctor of six years experience, had also assessed Ethan and not picked up on the signs of infection.

“If there were any signs I would have picked it up at that point in time,” he said.

“I can only speak about when I saw him. I would definitely have made a note of that.”

But he said his assessment only gave him a “snapshot” of the baby, and the assessment was also dependent on staff notes.

Ethan spent one night at home, where his condition deteriorated and his parents took him back to hospital the following morning.

Before they left the house Ethan stopped breathing and an ambulance was called but, despite the efforts of his dad, paramedics, and A&E staff back at the hospital, Ethan died later that morning.

Crucial evidence came from expert witness Dr Mark Anthony, a paediatric doctor with 20 years experience who specialised in infections.

“Are you satisfied that Ethan did have evolving sepsis (from his birth),” asked the coroner.

“Yes,” replied Dr Anthony. “I have very little doubt in my mind. The parents’ history indicates the same.

“Very subtle signs on the video and audio suggest the same as well. My understanding of infection is that is how it presents.”

Dr Anthony stressed the signs of infection were subtle and that Ethan had appeared in good condition from what he had seen.

He said: “He’s not somebody I would have thought would become so unwell so quickly, if I hadn’t heard the long respiratory phase.

“One could argue four professionals didn’t realise he was unwell.”

He said: “In the practical world, it’s excusable that the doctors and midwives didn’t recognise that this baby had been unwell. It’s likely that elsewhere in the UK this same scenario will happen again.”

Dr Anthony added that cases such as Ethan’s were rare but should serve as a warning for healthcare experts to heed parents’ concerns. In almost every case one could look back through the notes and the parents were anxious, and staff were not.

“The reason is that the middle experience staff also see the same signs in very well babies – not feeding, funny breathing.

“I hold my hands up – I should have checked the temperature and I didn’t" - midwife Gill Marchant

“So one has to go through a learning curve of realising the difference between the normal and the subtle abnormal. They start off very cautious and become overbold and then they become very cautious again.”

The lesson was, he added: “If parents are anxious, we should be anxious too.”

In conclusion, Mrs Harding noted the signs of infection detected by Mrs Verrin, and accepted her evidence on the issue of Ethan's lack of feeding, above that of the midwives, who thought Ethan had fed adequately.

Furthermore she accepted Ethan had not been overwrapped, which Gill Marchant had suggested could be the cause of his temperature, adding: “Gill Marchant did not take a second recording of Ethan’s temperature. She accepts she should have.”

But crucially she said the signs were subtle, and it was therefore understandable they had been missed by staff.

"I am not satisfied that the practitioners ought to have undertaken an infection screen and started Ethan on antibiotics," she said. "The only short form conclusion to me is one of natural causes."