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.