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Mid Staffs inquest told of nursing mistake in twins death

Two nurses delivered a massive overdose of morphine to twin baby boys who later died after being born at Stafford Hospital, an inquest has heard.

South Staffordshire Coroner Andrew Haigh heard the two boys, Alfie and Harry McQuillan, were given 12 and 17 times the prescribed dose by a nurse with no experience of delivering the drug to babies.

The twins were born prematurely at 27 weeks at the Mid Staffordshire Foundation Trust on 30 October 2010.

Morphine was prescribed to relax the twins but the inquest heard nurses Lisa Lucas and Joanne Thompson were unsure of the dosage and had to read the morphine protocol. However, they then still got the dose wrong.

Instead of the prescribed 50 micrograms over an hour, 600mg was given to Alfie and 850mg to Harry in just 30 minutes.

Ms Lucas, a staff nurse, made up the infusion and told the inquest she was given the levels by senior staff nurse Joanne Thompson, who told her they were correct.

She admitted both failed to spot the correct dosage in the drug protocol guide.

“We missed it, I don’t know how but we missed it. I cannot forgive myself for not checking harder,” she said.

The twins were transferred to the University Hospital of North Staffordshire but died on 1 November.

A post mortem concluded the twins had died as a result of their extreme immaturity.

David Field, head of neonatal medicine at Leicester University, gave evidence to the inquest on Wednesday and said the morphine overdose had “materially contributed” to the twins death.

He said Mid Staffordshire had received the mother because she would have bled to death before reaching the North Staffordshire hospital.

This meant the babies were delivered at 5am when staffing levels were low and although he said nurses initially coped well, they were doing many different jobs. “And in that process, an error occurred,” he said.

Professor Field added: “The hospital was faced with two unstable twins in a setting where expertise was strictly limited. Had they been in a different setting, possibly the babies would have been handled differently and possibly the outcome would have been different.”

Coroner Andrew Haigh will record his verdict on 23 May.

Readers' comments (20)

  • Adam Roxby

    Such a tradgic story. I really feel for everyone involved.

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  • michael stone

    Instead of the prescribed 50 micrograms over an hour, 600mg was given to Alfie and 850mg to Harry in just 30 minutes.

    were given 12 and 17 times the prescribed dose

    What am I missing, here ? 50 micrograms, even if that is supposed to mean 50 micrograms per minute for an hour, only comes to 3 milligrams in total. 600 mg is not 12 times 3 mg ! Or doesn't the NT author understand the difference between milligrams and micrograms ?

    And yes, it is very distressing for everyone involved !

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  • IF the nurses were paediatric nurses then there is really no excuse for the error, as they would have received appropriate training. I've just completed classroom training in IV antibiotics administration and have witnessed it being administered to an adult patient but I will not allow myself to administer until I feel completely competent and confident to do so. If in doubt, leave it out. My heart goes out to the parents of the twins.

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  • anon 11.32 - the media states they got 10 times the dose, seems like few can do the maths.

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  • Strange that Shaun Lintern has failed to mention in the article what specialist qualifications the nurses had.

    Anonymous | 4-May-2012 1:02 pm

    there is 'really no excuse' whoever administered the drugs and presumably these were registered nurses practising within the code of professional conduct otherwise they should not have been administering the drugs at all, except under supervision of a qualified nurse who had checked the dose.

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  • This problem has been endemic for many years. The inability of some nurses to undertake simple arithmetical processes is a disgrace and puts patients at risk.

    No one should be allowed to "qualify" unless and until they can perform simple calculations and KNOW how many micrograms make a gram !!

    Over the years I must have spent hours tutoring colleagues in simple maths. I will never understand how someone is allowed to register when they have a huge problem with drug calculations.

    In "critical care" environments it is of particular importance for nurses to be competent in dosage calculations and it is the responsibility of "Management" to ensure that no arithmetically challenged nurse is employed in these areas.

    Finally individuals should be aware of any deficiency they have. It is an individual responsibility to seek help in rectifying any professional deficiency and individuals should declare their lack of competence and refuse to undertake critical calculations if they are not sure of their skills.

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  • when staffing levels were low and although he said nurses initially coped well, they were doing many different jobs. “And in that process, an error occurred,”
    And this is the sentence that says it all,its is heartbreaking for everyone,these nurses have to live with this for the rest of their lives,but this could happen in any setting any where now.

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  • JRT is 100% correct.

    you cannot make excuses for incompetent practice from any registered healthcare professional and especially that with such a tragic outcome as described above. It is up to nurses to acknowledge and address any shortcomings before undertaking any care.

    It is a problem however when a nurse is shunted off their own ward at short notice to fill in where there is a shortage in an area where they have no experience which, with management, is often non-negotiable, but even then it is their sole responsibility to say which duties they are not competent to perform.

    Just when i left my hospital non-clinical management wanted to introduce a scheme where general adult nurses no longer had their own ward but were put where they were needed on each shift - presumably with the idea of saving personnel and costs. Nurses were totally against this idea for very many obvious reasons like breaking up their team, having a ward to identify with, dropping standards of care, working in less familiar environments, not building up therapeutic relationships with their patients, etc. and their major argument of not being competent in other areas of expertise. Management's retort to this was nurses are generalists and adult trained they should be prepared to work anywhere, perhaps with a few exceptions in highly specialist areas - but in their view many of the adult departments in medicine, surgery, etc. were one and the same!

    As I left at that time I do not know of the further developments but cannot envisage that it is a scheme which would really work.

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  • michael stone

    Anonymous | 5-May-2012 8:24 am

    anon 11.32 - the media states they got 10 times the dose, seems like few can do the maths.

    This isn't directly relevant to that tragedy, but it is relevant to 'the media states they got 10 times the dose', and to all comparatives of 10, 100, etc.

    If you perform a calculation, and suspect you are wrong by about 10x, then naturally you wonder if you have misplaced a decimal place.

    But a comment of '10 times too much' about an error, might mean 'about 10 times' - i.e. perhaps 8 or 9 times, or perhaps 11 or 12 times: it can be used to establish 'the order of magnitude'.

    But in the piece above, 12 and 17 were used - you say 12 if you don't mean 11 or 13, etc.

    Understanding that sometimes numbers require precision, and at other times they don't, is necessary - and some conversions just shouldn't be made (for example, 'within 3 days' should never be converted to 'within 72 hours' because it then implies much more certainty than was present in the original).

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  • Wow Didnt a Doctor prescribe the doseage???
    Why wasnt Neonatal Nurses involved???

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  • Have they been dismissed or moved to a position where they cannot do harm?

    Google tells me the usual dose is 10ug/kg/hour so yes it is around 50microgrammes.

    Author please note and learn for life
    a microgramme is abbreviated 1mcg or (better) 1ug
    1000 microgrammes makes 1 milligramme, which is abbreviated 1mg
    1000mg makes 1 gramme
    1000000ug makes 1 gramme
    There will be a test!

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  • 600mg was given to Alfie and 850mg to Harry . This dose will kill even the biggest adult on earth !

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  • how is it possible? Morphine iv is delivered in 10 mg ampoules, at least where I worked, and for adults.

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  • If a nurse hasn't been involved in drug calculations for some time then he/she would need to retrain in this area/do some homework. It is down to the individual nurse to take responsibility for their actions, ackowledge gaps in their knowledge/expertise. Putting one's hands up and saying "I can't remember how to do this" or "I can't do this without making a mistake" is not an admission of failure, it is a justifiable reason for not doing something regardless of whether you have been given an order to do it or whether you are short staffed. The NMC Code is very clear on this, it's there to protect patients and it's something that we can use to protect ourselves.

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  • I would recommend that all nurses carry around a laminated card in their pocket which shows how many mcg in a g etc. If in doubt of any prescription or calculation, contact your local pharmacist. Our pharmacist knows his stuff for sure. I was told that many doctors make errors which are picked up at pharmacy level.

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  • 60 ampoules and 85 ampoules would have had to have been used - where on earth do hospitals have these huge amount in a paediatric CD cupboard?

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  • Anonymous | 9-May-2012 2:51 am

    how would any nurse stand there drawing up so many ampoules of morphine without questioning it?

    it happened to me just once in my career when I had to draw up a very large number of ampoules of Akineton, only available in small doses, to get the prescribed dose for a patient who required it as an antidote to the side effects of another drug they had been administered.

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  • From Anonymous | 8-May-2012 2:57 pm and 7:18 am

    In view of the inconsistencies in reporting in the press (here and in several newspapers) over the dosages of morphine administered it would be judicious to wait until the coroner's verdict is published.

    "The twins' parents, Miss Dean and Phillip McQuillin, said they were "deeply upset and distressed". The coroner Andrew Haigh will record his verdict on May 23."

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  • michael stone

    ram seeereekissoon | 8-May-2012 2:36 pm

    It was an enormous dose, assuming this mistake wasn't in the calculation (in other words, unless the nurses had not believed they were administering 600 and 850 mg doses).

    My elderly BNF suggests that during adult palliative care, up to 2 doses of 500 mg per day of morphine might be administered, if lower doses didn't work - but those are dying adult patients, and adults are much larger than children.

    I assume, the problem was that these nurses did not realise how much morphine they were administering - the alternative, of not grasping that a huge morphine overdose will kill someone, seems even more worrying !

    It was hugely upsetting all around, whatever the reason was !

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  • DH Agent - as if ! | 9-May-2012 11:34 am

    why keep speculating

    wait and read the coroner's report

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