Little Masen Rushton-Walley was just eight days old when his breathing tube became dislodged while he was being cared for by nurses at Saint Mary’s Hospital in Manchester.
His death came just days after twin brother Kole died at the Royal Stoke University Hospital following the pair's birth at just 28 weeks in May 2016.
Devastated parents Nicola and Daniel, both 30, now say little Masen "should still be with us" after it emerged doctors missed chances to save him.
During an inquest held at Manchester town hall yesterday, Coroner Sally Hatfield said a delay in recognising his breathing tube had become dislodged contributed to his death.
Heartbroken Nicola said in a statement: “We are still coming to terms with losing Masen and Kole, but I hope that if any good can come from our loss, it will be that lessons will be learned and that I can help other families.
“No parents should have to go through what Daniel and I have gone through.
"The pain is excruciating and not a day goes by where I don’t think about how if things had been done differently, Masen would still be with us now.
“We truly hope that more can be done to improve care standards so that other families do not face the nightmare we have been through.”
Masen had been taken to Saint Mary’s Hospital to be treated for a suspected bowel infection on May 5.
Days later, his parents were reassured by ward staff their son was ‘stable’ and told to go and get some rest.
But hours later they received a panicked phone call telling them to return "immediately" after the newborn went into cardiac arrest.
He sadly passed away on the morning of May 13 after his parents made the heartbreaking decision to end resuscitation efforts.
The dedicated nurse responsible for Masen, Jordan Washington, told the hearing she had 'no concerns' in the hours leading up to Masen's death.
She changed Masen's position from left to right in order to “relieve pressure" – a standard procedure carried out on premature babies – while another nurse, Adele Fitzgerald, assisted to move the tubing.
The procedure works by briefly disconnecting a section of the breathing tube while the baby is moved, before it is reconnected, the court was told.
Nurse Washington said there is a “small risk” of the tube becoming dislodged when carrying out the procedure, but she believed it had been successful by Masen's "pink" colour.
It wasn’t until a saturation monitor attached to him began sounding an alarm that the nurses suspected anything might be wrong.
The ventilator machine itself then began “alarming,” which Nurse Washington said she thought could be in response to excess water in the breathing tube or a lack of oxygen.
The nurses said they repeated steps in line with hospital procedure to flush out any excess water, but the alarm continued to ring.
Both nurses then frantically switched to manual ventilation using a mask and a pump when Masen stopped moving and began to turn pale in colour.
Nicola and her Daniel were then forced to make the devastating decision to end resuscitation efforts after it became clear their son was not responding.
Dr Catherine Johnson, a neonatal consultant from the University Trust, confirmed there had been “a time when an opportunity to save Masen had been missed”.
Dr Johnson said she believed the tube had become dislodged, but that staff had not picked up on this quickly enough.
She said: "On balance, had that been done sooner, I think there was a chance that resuscitation would have been successful."
Two heart-monitoring options had been available to staff, but they chose to only use one to care for Masen.
The hospital has since been forced to apologise.
A Manchester University NHS Foundation Trust spokesman said: “We wish to offer our sincere condolences and apologies to Masen’s family for the loss of their much loved baby.
“Our heartfelt sympathies go out to them.
“Following Masen’s death, the Trust undertook an immediate and thorough investigation to examine the care he received.
“We wish to reassure our patients and the public that we have taken steps to ensure that lessons have been learnt from this sad incident."
In a narrative conclusion, Assistant Coroner Sally Hatfield said: "It is agreed there had been a dislodgement but it had not been appreciated quickly enough and when resuscitation started it was already too late.
"By the time the problem was recognised, Masen had suffered a cardiorespiratory arrest and could not have been revived.”
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