A baby who was born weighing just 11oz (328g) and had to be kept in a sandwich bag died a few weeks after returning home from hospital, an inquest has heard.

Robyn Chambers, from Malpas, Newport, had brain damage after she was born at 23 weeks in March 2023 at the Grange Hospital, Cwmbran.

She was so small that she fitted in the palm of a hand and was put in a sandwich bag to keep her vital organs warm while she grew and spent most of her life in hospital.

Gwent’s Senior Coroner Caroline Saunders said there were “failures” by Welsh Ambulance Service following a 999 call by Robyn’s mother, but she concluded Robyn died from natural causes.

While at home in October 2024, Robyn’s oxygen levels dropped, and following a few days in Noah’s Ark Children Hospital, she died on 2 November at Tŷ Hafan Children’s Hospice.

The inquest heard on 26 October 2024, Robyn’s parents, Chantelle and Daniel, became “extremely worried” about her condition.

Her blood oxygen saturation levels had lowered to between 50 and 60%, which is significantly low.

They phoned an ambulance but were told it would take eight hours, so they took her to hospital themselves.

“We had to carry Robyn out at midnight on our own in the dark and cold,” the coroner said on behalf of Chantelle and Daniel.

The coroner told the inquest she found there were “failures” by Welsh Ambulance Service when Robyn’s parents made the 999 call that night.

There was an incorrect record in response to Robyn’s consciousness, Caroline Saunders said, and a failure to record her blood oxygen saturation levels.

A correct record would have prompted a clinician to trigger a red category response, she said, meaning Robyn would have arrived at hospital sooner as the target time for an ambulance within that category is eight minutes.

However, the coroner said Robyn already had a chest infection and the outcome would not have changed had she arrived at hospital sooner.

She had developed pneumonia and the effects were “overwhelming”, said the coroner.

The inquest heard evidence from Melanie Collier from the Welsh Ambulance Service who said that changes had been made to the system.

The inquest also heard from Gillian Pleming from the service who said it was experiencing “a high number of calls in the area” at the time.

Despite the protocol selection from the clinical support desk being correct, Ms Pleming said, the category was not.

“I’m reassured that Welsh Ambulance Service has made changes,” the coroner told the inquest.

Ms Saunders said she would write to Aneurin Bevan University Health Board regarding “unacceptable delays” in the handover of patients, which means that ambulances can’t be released to attend to patients.

Welsh Ambulance Service and Aneurin Bevan University Health Board have been contacted for comment.