A senior coroner has called for change after a report found that a baby born at the Rosie Hospital, in Cambridge, died after being given a contaminated feeding method.

Oscar Barker was born at the Rosie, which is part of Addenbrooke's Hospital, Cambridge, on May 27, 2014. He was one of twins, born prematurely at 28 weeks by C-section.

He was given Total Parenteral Nutrition (TPN), which is a feeding method. It is a formula containing nutrients and is given intravenously.

Oscar's health deteriorated, and on June 16, Oscar was noted to have multi-organ failure and a sepsis diagnosis. He had blood cultures taken on June 16 and 18, and the tip of the long line was sent off for analysis on June 16.

The blood cultures came back negative, however the long line was confirmed to have Bacillus, later identified as Bc.44.

Oscar sadly died on June 19, 2014. His cause of death was multi-organ failure and Bacillus cereus (Bc.44) sepsis.

A Prevention of Future Deaths report looked into Oscar's death, as well as the death of two other babies - Aviva Otte and Yousef Al-Kharboush. The report does not state where Aviva and Yousef were born.

Aviva, Oscar and Yousef all received TPN which was contaminated by Bacillus cereus. Aviva died on January 2, 2014 and Yousef died on June 1, 2014.

The report, conducted by senior coroner Dr Julian Morris, found that the hospital Trust responsible for Aviva Otte had conducted an analysis into TPN, but no source for the outbreak was found.

Dr Morris wrote that the Trust did not share its findings on TPN by using a section 10 exemption, which allows pharmacists to make a limited quantity of medicine for a specific patient, or to the wider market.

According to the report: "The current reporting structures (for a section 10 entity) involve reporting to NHSE and the CQC but the threshold or necessity for such reporting appears unclear and, in essence, up to the Trust."

Dr Morris sent the report to the Secretary of State for Health and Social Care, the NHS Regional Director for London, the Interim Chief Executive of the Care Quality Commission, and the Chief Executive of Medicines, and Healthcare Products Regulatory Agency (MHRA).

The coroner said those who had received the report had a duty to respond within 56 days of it being published, which will be January 8, 2025.