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.