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Nurse struck off for fatal overdose


A nurse who administered an overdose of salt to a baby who later died has been struck off the medical register.

The concentration of sodium chloride was approximately 10 times that expected from the prescription for four-month-old Samuel McIntosh, who died at Nottingham’s Queen’s Medical Centre (QMC) in July 2009.

An inquest into the death the following year heard that two nurses who were involved in the “dreadful mistake” which led to the death could not explain how the error occurred.

The inquest heard 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.

As a result of the mistake, Samuel was wrongly given 50ml of a sodium chloride solution despite a registrar prescribing just 5ml.

Staff nurse Swinburn was struck off by a fitness to practise panel of the conduct and competence committee of the Nursing and Midwifery Council in London today.

Tests carried out 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.

Samuel was born prematurely at Nottingham’s City Hospital on March 1 2009, and weighed 1lb 4oz (580g) - around a sixth of the normal weight for a full-term baby.

He was transferred to the QMC aged 18 days and although he required intravenous feeding and underwent a bowel operation and eye surgery, his weight eventually rose to 6lb 3oz (2.8kg) and he would have been expected to survive.

Swinburn has 28 days to appeal against the decision of the panel. A suspension order is in place to prevent her working as a nurse.


Readers' comments (20)

  • Am I reading this right, two nurses check a prescription but only one nurse is suspended!!!!

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  • I also wonder why only one nurse was struck off ??

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  • Yes it also baffles me why only the staff nurse is struck off. What about the sister that checked the prescription with her?

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  • Presumably the one that actually administered it?

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  • Me too.
    Perhaps the hearing of the other nurse is still in progress. Why has it taken over 3 years to reach this decision?
    I don't know the full circumstances of the incident but it highlights the importance of not interrupting staff during preparation/administration of medicines. Also the importance of staff ensuring adequate conditions for this important role. Above all it highlights the importance of
    holding management to account when adequate conditions are not provided.
    For this to happen staff have to make concerns about resources known to management. All too often the management response is " you have to prioritise and manage your time better", along with other veiled threats.
    Many staff have lost their jobs in such situations, mainly because colleagues will not support the lone courageous soul who speaks out. It seems to be more important to stay in the inner circle ensuring a better chance of promotion etc. Many corrupt/ incompetent managers do not want to hear what they regard as bad news ie (adequate resources required). and so, the spiral of risk is maintained. Patients are injured and some die. We do not hear about all of them.
    Does this sound familiar?
    Patients first was launched last year to reduce death and avoidable harm to patients and is making good progress.

    or email

    There is a way of providing safe care and we all have to play our part. No point in expressing shock/horror when fatalities occur.
    The pain and loss of this baby will remain with this family forever. It should never happen again and lessons have to be learned.
    Kathleen White Edinburgh

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  • The article states that the nurse was struck off the "medical register". Was she a doctor then?

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  • The two staff members involved will have this on their consciences for the rest of their lives. The loss to the parents is immeasurable. There but for the grace of God .....

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  • To Anonymous 21-OCT-2012 0:18

    The term "medical register" is an error The article makes it clear that she was a staff nurse. Some journalists might simply not be familiar with the various healthcare registers.

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  • I have made drug administration errors relating to oral medication. I was working under pressure and was very tired. On 2 occasions the errors were partly due the layout of the drug chart; it was easy to misread and medication was given to the right patient, in the right dose but at the wrong time. The place I was working in at the time have now changed their drug charts. All I can say is that no harm came to the patients, a GP was called on both occasions and the patients were carefully monitored. I now double check everything I do even if it means a drug round takes twice as long. I have a good track record in nursing and am very conscientious and yet I still made mistakes. I would be interested to know how many other nurses on NT would be willing to admit to making such errors.

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  • This is a dreadful situation. The family will never recover from this. In this case it may be that the proportion of blame has been seen to be with the staff nurse. However when looking at the cause of accidents incidents one step in the process has been missed I.e the domino effect. Any nurse who has worked in a busy unit has experienced situations where they are distracted but some part of the process/procedure has been missed. I am sure that the two nurses involved in this will never come to terms with this. And as the colleague above has commented there but for the grace of god go I .

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