An inquest has revealed that an underfunded neonatal unit was 16 nurses short staffed when a premature baby died on 2 June 2009.

Charlotte Jones was born prematurely at 23 weeks. Sadly, her twin sister Alexia died after just 21 hours.

Charlotte was due to be transferred from Southend University Hospital, Essex, to Addenbrooke’s Hospital, Cambridge, when her lungs gave up and repeated resuscitation attempts failed.

Whilst the hospital was cleared of any wrongdoing, an inquest into the death revealed that the neonatal unit was seriously short-staffed at the time of Charlotte’s death and that ‘funding issues’ had put the unit under pressure.

The hospital has since reassured the public that it is now just three staff members short and is actively recruiting.

The evidence also highlighted concerns relating to transporting critical patients. It transpired that staff were going to take Charlotte to the Cambridge-based Addenbrooke’s Hospital themselves as the East of England’s Acute Neonatal transfer service was not available at night.

Offering further reassurance to the public, the trust has confirmed that this service in East Anglia is now available 24 hours a day.

Charlotte, who suffered with feeding difficulties, was due to undergo surgery at Addenbrooke’s.

Recording a narrative verdict, the coroner said: “Despite two paediatric post mortem examinations, there is no definite explanation for why Charlotte died.”

Guy Forster, a specialist clinical negligence solicitor who has represented dozens of families affected by stillbirth and neonatal death, commented: “In my experience, when families suffer a tragedy like this the most important thing is to establish why things went wrong and whether anything could have been done to prevent it from happening. All too often families are left waiting for answers and feel they have no option but to investigate a legal claim or have to wait for a lengthy inquest process to conclude. It is vitally important that hospitals do all they can to provide the explanations families need as soon as possible.”