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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)

  • It is extremely sad to learn that a staff nurse has been struck off the register, but most extreme to learn a baby died as a result. The circumstances are still fuzzy - how could the nurses not have stuck religiously to the script/instruction of the doctor? And if doubt, why didn't they ask - 'baby unit' is always a critical unit - Nurses becareful, be very very careful!!!!!

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  • I think stress has a very big part to play, they were distracted and as a result this dreadful incident happened. Wards are very busy places and there are always demands on a nurses time. Lessons I hope would have been learnt from this incident so as no other patient will come to harm.

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  • When IV preparations require 2 nurses to check them, they are both accountable for the correct administration, and they are both accountable and answerable for their actions despite the fact that only one nurse can physically administer the IV medication.
    Why then has only the nurse been taken to task and not both members of staff.
    When checking or administering medication you should not be disturbed by other staff. From experience I know that if medications are checked with senior staff such as Sister, then they are regularly asked about things that could wait until after the medicine has been correctly checked and administered. Medication is the most important part of nursing care and we cannot afford to get it wrong!!

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  • The misconduct hearing was not only relating to the administration error but other conduct issues, including sleeping on duty and posting a photograph on Facebook that showed the baby without his parents' consent. The NMC ruling described her practice as both "wide-ranging misconduct" and demonstrating "her lack of insight". You can read the full hearing on the NMC website.

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  • I'm not trying to mitigate the circumstances but why is it that unlike nurses, doctors are not struck off when they kill patients?

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  • what a sad case, nurses must not be interrupted when they are preparing any form of medication - two nurses check an IV drug, if both make an error then surely both are equally accountable. I don't suppose they did it deliberately.

    I had a friend whose baby was given the wrong dose of IV fluids over 20 years ago - have things not improved?

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  • Extremely sad case but definitely not the only one like it. This just underpins the extreme caution we must take when preparing medications and in clinical decision making. Our knowledge, skills and lack of attention to detail can cause serious harm. There are five drug rights (or 6 for paediatrics as weight is equally important) and these rights have been drummed into us at university since day one! I pray for the poor family of the child! And for the nurses as they must live with their careless mistake for the rest of their lives :(

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  • As several people have stated why is only one nurse struck off? I also have been involved in medication errors which fortunately have been resolved prior to reaching the patient. Again the 2nd checker was not disciplined which makes me ask why do we as nurses put ourselves at risk on such a daily task. It should be those that are checking have the same responsibility as those administering as per the nurses competences. I fell for the nurse struck off knowing that her colleague who was also involved in this awful incident can go back to work as if nothing has occured!

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  • Interested to find out why the sister did not get struck off as she also was involved in preparing the solution.

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  • As is pointed out above, the full report explains that the striking-off order was not because of this one drug incident in isolation but because of other professional conduct issues and the nurse's lack of insight into her practice and conduct. The senior nurse's involvement was limited to this one incident.

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