Catalogue of errors led to premature baby’s death
When Michelle’s baby daughter, born prematurely, died less than 24 hours after she was born, she came to Inez Brown at Medical Accident Group to discover what had happened and why.
She had gone into hospital two days beforehand suffering from back and abdominal pain; she was examined treated, admitted to a ward and then later sent home. She came back suffering from more pain and with bleeding – her daughter was born very shortly after that and taken to the neo-natal unit.
The baby was not strong – her initial vital signs were low, though they improved – so medication was prescribed and she was monitored overnight. The following morning, after the ward round, a change in treatment was prescribed.
Shortly after the new treatment began, the baby became very ill and within three hours she had died.
Investigations showed that the new treatment with vamin, a fluid designed to give essential nutrients, had been given alongside the original vamin treatment, rather than replacing it, so the baby had been given far too much fluid; the prescription was for a 500ml bag rather than a 50ml bag.
The hospital admitted that there had been:
- A prescribing error – 500ml bag of fluid prescribed instead of 50ml.
- An administration error – staff did not comply with the hospital’s medicines policy as the prescription chart was not checked prior to drawing up fluids.
- Failure to ensure that the right equipment i.e. an infusion pump was available before treatment began.
- Failure to deal with that lack of equipment.
- interruption of staff, because of workload pressures, mid-way through the medication checking procedure.
- Failure to check the prescription chart before scrubbing and drawing up fluids.
- Numerous missed opportunities to disconnect the fluids.
- Lack of handover of the baby’s care and no one visually reviewing the fluids being administered and a lack of proper care of Michelle’s baby because of other demands on staff time.
- A lack of recognition of the symbol indicating a very high blood sugar on the gas machine printout.
Failures of care
Michelle came to Inez for help, after she and her partner suffered from deep shock and distress at losing their daughter. She was relieved to find that Inez’s support made the legal process easier – Michelle said “her easy approach and tremendous knowledge in this area helped to take the pressure out of the whole litigation process.”
Inez said: “The baby died because of a catalogue of errors by the hospital and its staff – Michelle lost her child because of fundamental failures of care. I was glad to be able to give her the answers she needed about why her baby died, and to ensure that she and her partner received £50,000 in compensation.
“It is absolutely clear that no amount of money could ever compensate them properly for the loss of their child – we can only hope that the hospital has learned from the mistakes made then, so that others do not have to suffer in the same way in future.”