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Coroner finds 'failings' in Mid Staffs twin deaths


A coroner has ruled there were failings in the care of twin babies who died after nurses at Stafford Hospital gave them a massive overdose of morphine.

South Staffordshire Coroner Andrew Haigh found twins, Alfie and Harry McQuillan, received “sub-optimal care” from nurses at Mid Staffordshire Foundation Trust shortly after their birth at 27 weeks in October 2010.

Recording a narrative verdict on the events which led to the twins death, the coroner also criticised the “wide discrepancy” in evidence given to the inquest by the two nurses involved.

As previously reported by Nursing Times, an inquest earlier this month heard the two boys were given 12 and 17 times the prescribed dose of morphine by a nurse with no experience of delivering the drug to babies.

Staff nurse Lisa Lucas and senior staff nurse Joanne Thompson were unsure of the dosage and had to read the morphine protocol. But despite this, they still got the dose wrong, the inquest was told.

The twins were subsequently transferred to the University Hospital of North Staffordshire. However, they died on 1 November just days before the public inquiry into the scandal of care at the Mid Staffordshire Trust was due to begin.

Coroner Andrew Haigh said the babies treatment after birth was “suboptimal” and “there were failings in the care the twins received”.

He said the cause of death was “‘complications of extreme prematurity”, but added: “I believe on balance that morphine is likely to have played a role in the children’s deaths, and therefore they are not natural deaths.”

He also said there was a “wide discrepancy” in the evidence given at the inquest by the two nurses, one of whom he said had “little understanding as to what she was to infuse into the twins and how to do it”.

Mr Haigh said the overdoses were administered at the end of a night shift, when the “risk of error…was very high”.

He concluded his verdict saying: “The circumstances of the deaths were particularly tragic, and I am sorry it has happened to them.”

Maggie Oldham, chief operating officer at Mid Staffordshire Foundation Trust said: “Our deepest sympathy remains with Alfie and Harry’s parents and their loved ones.

“We are very sorry that the care we provided was not good enough. This has been a long and difficult process for their entire family and our thoughts remain with them at this time.”


Readers' comments (2)

  • I cannot comprehend the feelings of the parents and family at this time that will last for probably a lifetime.

    I also feel for the nurses involved. They didn't set out to make this tragic error, however , clearly this was the ultimate significant event. We must remind ourselves there is a Trust to take into account in all of this (again).

    Why were they looking after these babies when clearly not equipped with the key skills?

    Where was the supervision? What have we heard from the medical staff on this scenario? Nothing as yet - how unusual NOT!
    Are we looking at a 'swiss cheese' effect within this system? If so - maybe some more investigating within the unit should be undertaken in the interests of other infants & families?

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  • What on earth is going on "cause of death complications of extreme prematurity" is the coronor saying should the twins have been full term they would have coped with 12 and 17 times the morphine given?????

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