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'Distracted' nurses' drug error killed baby


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”.


Readers' comments (9)

  • This is such a sad situation and one that should never happen. What did the other nurse check though? the same 50mls? and was the drugchart ever checked? I hope nothing sinister happened between two of the nurses. I feel so much for the parent of Samuel, to have lost a baby due to the negligence of the nurses!

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  • So sad that someone had to die to make changes, where this staff properly given managerial and clinical supervision?

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  • The anonymous writer of 25-Nov-2010 does not acknowledge that with humans, there is always a possibility of mistakes. Nurses are humans and it must be noted that they would not wish to be in the situation that they are now. No sane person would. The risks and demands of the role are only mentioned and critised at a time like this, yet there is no recognition or acknowledgement of their worth, or adequate support in payment and other areas needed. They handle life everyday like the doctors do, but are paid far less and disrespected everyday by the ungrateful public. How sad!.

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  • Anonymous 27-Nov 0.22am ...where are you coming from. Are you completely devoid of feeling. Your ramble ends with complaining about the disrespectful and ungrateful public and poor pay. May I suggest you get out of nursing, we have no room for people like you.

    A young baby DIED as a result of this incident...

    Yes anyone can make a mistake...but
    TWO nurses checking drugs should eliminate the chance of error if they follow procedure properly. So a mistake like this takes it a step is called negligence.

    My heart goes out to the parents

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  • i worked in paediatric hdu nursing for several years as a senior nurse. my fear was always that something like this would happen 'on my watch'. Not because i was not aware of the drug administration policy but because every day we were expected to take on more and more responsibility and the dependency levels of the children increased. For me i knew i could not accept any more when my named consultant told me i had to choose only one of the following appropriate equipment, appropriate staff training or more staff members for my team.

    This is a really sad situation for every one converned.

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  • Thank you to anonymous writers of 27-Nov-2010 0:22 am and 27-Nov-2010 10:30 pm. The question of how sad it is that a baby died is not an issue here. It is well acnowledged by both writers. The point that they both raise is clear, which is 'how do we stop it happening again'?
    Judith willis of 27-Nov-2010 5:19 am certainly needs to learn to be open minded and realistic in life and not simply be jugmental, ignorant and punitive. Please God, hope she is not in the management team or even in the nursing profession, or else what support would she give these poor nurses and her team?

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  • This is an undoubtably horrific situation for everyone involved and I think a lot of us are all privately saying 'there but for the grace of god go I...'. Moving away from this specific incident for a moment though, 'Distraction' incidents will increasingly become more common, as already overburdened Nurses find workloads continue to increase and staff numbers continue to fall. We are all silently screaming at this issue, but how many more incidents like this need to happen before something is done?

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  • Hello? There were supposedly TWO nurses checking this drug? What does the respondent mean by taking on more responsibility? This is normal practice - staffing levels are different to checking drugs correctly and competently. Yes, we must look at how this does not happen again but we need to take responsibility for our own careful administration. Frankly I dread to think how many drug errors go unnoticed and if noticed unreported with single nurse administration. Many I should think as I know that wrong TTO's get sent out with patients. It is down to accountability, common sense, competence and training. No amount of degrees in nursing will help prevent these errors until we train people to know what they are doing on a ward with living human beings and be responsible for what they do and THINK.

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  • The comment of ANONYMOUS 27-NOV 2010 00:22am is not a ramble or a complaint. He or she is simply describing real life.
    It is indescribably sad that a baby died. The bottom line is that everything should be done to make sure that such a tragedy never happens again.

    Lack of support and poor pay does indeed contribute to such errors. Many staff have to do extra jobs to survive. This leads to exhaustion, lack of concentration and the potential for errors.

    Anyone who cannot understand that is out of touch with reality.

    Nursing involves large responsibilities. One split second error can have shocking consequences. Most people understand that. Sadly, however many others do not.

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