A hospital boss insisted that changes have been made to protect unwell children following the death of a month-old twin boy.

A coroner questioned whether Epsom and St Helier University Hospitals NHS Trust has appropriately amended its provision of care during the inquest of Micah Smith last month.

Sep 23: Family tell inquest into their son's death his treatment "was utterly terrible"

Sep 24: Epsom Hospital boss apologises as coroner rules new born's death came after diagnosis errors

Micah Smith died from hydrocephalus – a condition in which excess fluid puts pressure on the brain and causes irreparable damage – on July 15 2013.

His inquest was held on September 22 and 23 this year.

Dr Karen Henderson, assistant coroner for Surrey Coroner Court, judged that a “delay in diagnosis” at Epsom Hospital left Micah with a “bleak chance of survival”.

She was concerned lessons might not have been learned and sufficient safeguarding measures put in place since the incident two years ago.

During the inquest, she said: “I want to know what the Trust understands about what has happened, what failings – if any – they recognise, and what they plan to do to change it.

“I need to know the whole scope with regard to the circumstances surrounding Micah’s death.

“I do not feel the evidence I tried to obtain yesterday allowed me to satisfy that part of my remit.”

Dr Jim Stephenson, joint head of microbiology at Epsom Hospital attended the inquest on behalf of Epsom and St Helier University Hospitals NHS Trust.

He said: “The process we were going through was, what lessons could be learned and what improvements could be made. 16 core concerns were arisen.”

After the inquest, joint medical director and deputy chief executive at Epsom Hospital, Dr Ruth Charlton, apologised for the hospital's failings.

But she insisted that initiatives introduced since Micah’s death – designed to identify unwell children early – and more paediatric consultants will prevent similarly ill infants dying.

She said: "On behalf of the trust, I would like to offer my heartfelt condolences to the family and loved ones of Micah Smith.

"We are deeply sorry that the care provided to Micah fell short of the standards that we would expect for our patients.

“Since this case, we have introduced a number of steps to reduce the risk of a similar occurrence ever happening again in future, including recruiting an additional four acute paediatric consultants to bolster our clinical capacity in this area.

“We have also introduced a children’s observation and severity tool – an observation and early warning system to help our staff identify unwell children quickly so that opportunities for early diagnoses are not missed.”