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Nurse admits giving infant salt overdose

A nurse has admitted administering an overdose of salt to a baby who later died, a medical tribunal has heard.

The concentration of sodium chloride was approximately 10 times that expected from the prescription for four-month-old Samuel McIntosh, who died at Nottingham’s Queen’s Medical Centre (QMC) in July 2009.

An inquest into the death the following year heard that two nurses who were involved in a “dreadful mistake” which led to the death could not explain how the error occurred.

The inquest heard that Sister Karen Thomas and staff nurse Louisa Swinburn were “distracted” by another staff member as they prepared a solution to correct Samuel’s low salt levels.

As a result of the mistake, Samuel was wrongly given 50ml of a sodium chloride solution despite a registrar prescribing just 5ml.

Tests conducted on a syringe after the mistake was spotted showed that the sodium chloride had also not been mixed with dextrose, as required by the prescription.

The error meant the infusion given to Samuel was 10 times the required concentration, causing swelling to his brain from which he died.

A fitness to practise panel of the conduct and competence committee of the Nursing and Midwifery Council in London heard that Ms Swinburn, who was not present for the hearing, had admitted administering an overdose of sodium chloride to Samuel, who is being called Baby A for the purposes of the hearing.

She admitted that the overdose related to a concentration of sodium chloride approximately 10 times that expected from the prescription.

She has also admitted posting on Facebook, on or around June 23, 2009, a photo of herself on duty at the Nottingham University Hospitals Trust, and the baby.

This was without the consent of the Trust, or the baby’s parents.

She denies charges that on the nightshift of June 22-23, 2009, she fell asleep while on duty, and that she appeared to be asleep in the photo.

The panel is to consider whether her alleged actions amounted to misconduct and if her fitness to practise is impaired.

At the inquest, Paul Balen, the solicitor acting for Samuel’s parents Robert and Sarah McIntosh, urged the Nottingham Coroner, Dr Nigel Chapman, to consider a verdict of unlawful killing.

But Dr Chapman recorded a narrative verdict after ruling that Samuel died after a “drug error” on the high dependency unit at the QMC.

Ms Thomas, who was in charge of the unit, told the inquest that she had no clear memory of what she actually did. There had been “a bit of an interruption”, she said.

Ms Swinburn told the inquest she could not recall opening five 10ml vials of sodium chloride, saying: “Nothing occurred to me at all that we had made an error.”

Samuel had been born prematurely at Nottingham’s City Hospital on March 1, 2009, and weighed 1lb 4oz (580g) - around a sixth of the normal weight for a full-term baby.

He was transferred to the QMC aged 18 days and although he required intravenous feeding and underwent a bowel operation and eye surgery, his weight eventually rose to 6lb 3oz (2.8kg) and he would have been expected to survive.

Dr Chapman said there was no doubt that a dreadful mistake had taken place, but ruled that it did not fall into the category of a gross failure.

Readers' comments (7)

  • Surely after this, the hospital should derive a policy that ensures that iv prescriptions are checked by a pharmacist and that their aseptic unit makes up the iv. There are many factors that contribute towards errors. It can happen to any nurse. Distractions are common and an area should be allocated to comply with medicine management guidelines.

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  • I agree with above comment I have suggested at my A&E dept that IV's should be prepared and checked in a quiet room by permanent pharmacy staff who wont be distracted, the prescriptions should be given in to be prepared by them thus saving nurses valuable care time and thus reducing risk of error and consequently deaths.

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  • I have worked with both these nurses in the past both have made an error - not done intentionally and are both kind, caring, experienced & compassionate. That does not take away what has happened - human error due to systems failures present in many neonatal and other intensive care units throughout the country. Complex IV drugs & calculations being made up in the clincial area, subject to interruptions, pressures of time over staffing vs patients, failing to follow the safety checks of IV admin from start to finish due to practice/time/habits/working knowledge of colleagues skills. My heart goes out to the staff involved & the family, think about your own practice for a few mins.
    As for the photo - unacceptable but I challenge every nurse/midwife who has done 12hr night shifts to truthfully say that they have never closed their eyes at that terrible time in the early hours, it does not mean you are sleeping?!

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  • Anon 19Oct 2.16pm

    Yes the photo was totally unacceptable the question is not so much about her eyes being closed but much more importantly WHY was a photo taken (a photo that also showed a patient) and posted on a public Internet forum - unprofessional and outrageous!

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  • I read about this case and think that the two issues need to be separated. The nurse was indeed foolish to take a photo of a child in her care and post to facebook. I am pediatric and over the years have taken many photos of children however I cannot imagine myself doing this now without seeking permission from the child's parents.

    The issue of the drug error is a separate issue. I would have like to know more about event. Was the error in the prescription, was the prescription hand written and easy to read, was it written in a manner that may have been open to misinterpretation? Was the error in the preparation? If two nurses were involved in the checking process are not both nurses equally responsible. Both nurses involved in the checking process are equally responsible for their actions. There is a comment that she cannot recall opening the vials and the number of vials required did not raise alarm bells. I am assuming that the fact that she opened 5 vials should have raised an alarm, an alarm that this volume of the drug was too much. Sadly health care professionals do make errors and when we do they can have catastrophic consequences. Nurses are often put in situations that quite frankly make it more likely to make an error. I saw this so much when I worked in Ireland a few years back. I am back working in Cnd and most of our medications come prepared. We rarely have to mix IV meds. When I was working back in Ireland I did not become IV certified because I thought it was too unsafe. Nurses were mixing up meds in areas that were busy, they were constantly being interrupted etc it was simply too unsafe. I was in the float pool and found working in A&E the worst area.
    If this nurse was negligent, then she needs to be held responsible, however if this was an error she should not be scape goated.
    Management should held accountable if they allowed unsafe situations/practices to prevail. Nurses should also ensure that when checking medications/blood etc that the two nurses complete the check independently and not rely on the other nurses calculations.
    Of course we must not forget the parents who lost their child.

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  • I feel very sorry for this nurse and obviously for the baby's family. It is all too easy for mistakes to be made due to interruptions and pressure of work. As a newly qualified bank nurse, I found it very disconcerting that a lot of other staff used to sign off on an IV without really checking it so I made a practice of actually repeating the prescription so they would know what they were signing for. I also double checked it again before setting it up.
    I don't know what more experienced staff think but I believe there should be a blueprint for the layout of a drug trolley. Then, it wouldn't matter which ward you worked on, you would always know where a particular drug was. That in itself would save time. I'm very sure others have felt under pressure when taking a long time over a drug round. Personally though, I'd rather be safe than sorry.

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  • Btw, many of my colleagues were horrified on t
    he occasions when I took a Kardex back to a doctor because I couldn't read a prescription therefore was not prepared to dispense it. Would you take a chance with a patient's safety?

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