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"A failure to ensure that health professionals in the neo-natal unit had background medical knowledge on this family, " for example, and a failure to properly respond in detail when one neo-natal nurse did express some concerns.
BBC: Doncaster children: Who are they?
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David Field, professor of neo-natal medicine at the University of Leicester, agreed better advice was needed.
BBC: NEWS | Health | Warning over infant mortality gap
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If neo-natal services in North Wales were "outsourced to England" it would be "an outrage".
BBC: Hywel, Betsi, Angela, Antoinette
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Pseudomonas bacteria like those which killed four babies have been traced to water taps in neo-natal units.
BBC: Health statement
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"We are changing every tap on every clinical hand washing basin in every neo-natal unit in Northern Ireland, " he explained.
BBC: Health statement
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Ms Hinds said that Sands (Stillbirth and Neo-natal Death Society) would be kept informed as the investigation progresses and that discussions over a permanent memorial would continue.
BBC: Mortonhall Crematorium: Baby ashes parents call for truth
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She built a state-of-the-art neo-natal unit, brought in experts to train the clinic's staff and established a program to cover the medical costs for babies born to impoverished mothers.
CNN: Giving teen moms the tools to change their lives
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Other factors contributing to the high increase in the number of Caesarean births included the size of the hospital, the availability of a neo-natal intensive care unit and the number of midwives on duty.
BBC: Huge rise in Caesarean births