Baby died after “red flag” signs of bowel obstruction were missed in phone consultation, inquest hears

An inquest into the death of a baby after an advanced neonatal nurse practitioner missed “red flag” signs of a bowel obstruction during a phone consultation has again cast the issue of safe remote care into the spotlight.

Jax Miller died at 1 day old of volvulus, which occurs when a loop of intestine twists around itself and causes a bowel obstruction. It is known to be a critical medical emergency.

A number of doctors have expressed concern about the case on social media, particularly about the lack of a face-to-face consultation and the wider issue of non-medical professionals taking on roles traditionally held by doctors.

Jax was born on 7 June 2023 at the Princess Royal Hospital in Sussex and discharged home after a normal newborn and infant physical exam. Only one feed had been recorded before discharge, and Jax’s mother had been concerned about his reluctance to feed. She had also reported that Jax had vomited several times, which was not further investigated.

After discharge Jax remained reluctant to feed and continued to vomit. The mother was not advised to attend hospital immediately and was reassured that all was fine.

The next morning Jax’s mother took him to the Royal Alexandra Children’s Hospital in Brighton, where doctors carried out a laparotomy for suspected volvulus. The surgeon found a 360° malrotation with a completely dead small bowel and concluded that his condition was incompatible with life. Jax was redirected to a palliative pathway and died that evening.

At the inquest on 1 October the coroner concluded that Jax had died from natural causes, but he said, “There was a missed opportunity to provide the baby with urgent medical care due to an omission in communicating to his mother the appropriate actions to be taken should his condition become acute.” However, the coroner did not conclude that a prevention of future deaths report was necessary or appropriate.

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Source: BMJ, 14 October 2025