Two nurses involved in a “dreadful mistake” that led to the death of a four-month-old baby have told an inquest they could not explain how the error occurred.
Nottingham coroner’s court heard that Samuel McIntosh died at the city’s Queen’s Medical Centre (QMC) in July last year after being given 10 times the prescribed dose of sodium chloride.
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The hearing was told 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.
The Nottingham coroner, Dr Nigel Chapman, was urged by the solicitor acting for Samuel’s parents 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 medical centre.
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.
Ms Thomas, who was in charge of the unit, told the inquest that she had no clear memory of what she actually did.
The nursing sister told Dr Chapman: “As we were getting ready to prepare it… there was a bit of an interruption. Then we turned back.
“I don’t remember at any point being uncertain.”
Giving her evidence, Ms Swinburn said she could not recall opening five 10ml vials of sodium chloride, telling the court: “Nothing occurred to me at all that we had made an error.”
New guidance has now been brought in to minimise the need for concentrated salt solution, infusion prescription charts on the neonatal unit have been changed, and a system has been brought in to ensure nurses are not interrupted when administering drugs.
A trust spokesman later confirmed that one of the nurses was no longer working for Nottingham University Hospitals NHS Trust because of what it described as an “unrelated incident”.