A coroner has criticised a health board following an E.coli outbreak at a hospital that killed two babies.
Five-day-old Hope Erin Evans and another child - referred to as Baby A1 - died after contracting a particularly deadly and antibiotic-resistant strain of the bacteria called ESBL.
An inquest in Swansea heard Baby A1's mother was diagnosed with the bug after having IVF treatment in India - and her positive test result was recorded in a medical notes from abroad.
Hope, who was born at 26 weeks gestation, and Baby A1, born 27 weeks into her mother's pregnancy, were in incubators next to one another on Singleton Hospital's neo-natal unit in November 2011.
The hearing was told their two containers were only two metres apart - which is less than the three metre distance recommended by the British Association of Perinatal Medicine.
Although Hope weighed just 730 grammes and had been born prematurely - she was still given a 75% chance of survival by doctors.
But within 72 hours her condition quickly worsened. She was pronounced dead when she was just five days old.
Hospital bosses at the Abertawe Bro Morgannwg health board said the unit had since undergone a multimillion-pound refurbishment and "major improvements" had been made. However, acting Swansea coroner Colin Phillips said he would still be writing up a Prevention Of Further Deaths report.
Among the problems he identified was a key hospital document not asking medics to check whether their patients had sought treatment outside of the UK.
He said: "We have heard the E.coli was probably transmitted between the babies and that the mother of Baby A1 tested positive for E.coli ESBL 14 weeks in her pregnancy. This finding was recorded in her medical notes.
"E.coli ESBL testing is not routinely done on arrival to maternity wards in this country, and tests are only carried out when an outbreak occurs.
"However, we have heard that the bacteria is common in places such as India due to the over-use of antibiotics - and that there are pockets of the UK where infection is rising.
"I will be writing a Prevention of Future Deaths report as I have concerns important patient information was not captured."
Hope's inquest also heard that had doctors discovered Mother A had E.coli they would have done things differently.
As well as using barrier nursing, Mother A and her two twins would have been placed in a cubicle on their own.
Mr Phillips also described the facilities at Singleton Hospital's neo-natal unit before the refurbishment as "poor" and "outdated".
"The number of sinks were inadequate for the number of cots and queues formed at peak periods," he added.
"The space between cots did not meet current standards and a central table was used for medical notes.
"However, despite these problems I have heard there was excellent hand hygiene in place."
The inquest also heard that originally Mother A had been treated at Prince Charles Hospital in Merthyr Tydfil before being transferred to Singleton after she went into labour early.
When transfers like this occur, the hearing was told, an "Inter Hospital Transfer Documentation" should be completed.
When Mother A1 arrived at Singleton this form had not been completed.
However, Mr Phillips said if the document had been completed it may have not made a difference because it did not ask the question about receiving treatment abroad.
The coroner added this was something which needed addressing - and prompted him to write a formal report on the issue.
He said: "I am concerned about the time lag and its been three years since Hope passed away and the issue here is to prevent further deaths."
Following investigations by Abertawe Bro Morgannwg University health board and watchdog Healthcare Inspectorate Wales, it still remains unclear exactly when, where and how Hope came to be infected.
In her evidence yesterday, consultant neo-natologist Dr Jean Matthes said it was "not possible to rule out cross-infection occurring".
The hearing was also told it was likely the "E.coli had been transmitted between the babies" - rather than coming from an outside source.
Mr Phillips recorded a narrative verdict, stating Hope died from sepsis as a result of contracting E.coli ESBL.
Family solicitor Peter Williams said Hope's parents Jonathan and Janette, who live in Aberdare, were too upset to speak after the hearing had concluded.
Mother A's second child - referred to as Baby A2 - survived and was discharged from hospital on December 29 2011.
ABMU health board said it wanted to offer its condolences again to the affected families.
A spokeswoman said: "Since this tragic event in November 2011, the neo-natal unit at Singleton Hospital has undergone a £3.2 million refurbishment to provide a very high quality environment for these precious babies - the most up-to-date in Wales.
"All clinical areas have been enlarged and completely modernised with new fixtures and fittings and equipment.
"The floor area for the intensive care cots, high dependency cots, and special care baby cots have all increased in size, quadrupling the space around every baby.
"A special isolation room has also been created for babies to greatly reduce the risk of cross-infection, and also protect those very vulnerable babies whose immune systems aren't as strong as others.
"Infection control audits also show a consistently excellent rate of compliance at the unit, and staff are committed to providing excellent, safe care for the babies in their care."
The health board said the new unit was also equipped with a 386,000 new heart rate monitor called "HeRO" which gave doctors earlier warnings of when a baby's condition was worsening.
"It is anticipated that HeRO will save an additional 20 babies' lives over the next 10 years, and reduce the number of sepsis episodes by over 60, avoiding long term damage to many babies and helping them to grow up as healthy as possible," the spokeswoman added.