Premature twins in “good” state die after being given fatal overdose of morphine at Stafford Hospital
Clinical Negligence News : 29 May 2012
Newborn twins Alfie and Harry McQuillin were said to be in a “good” state throughout the first few hours of their lives, despite the fact that they had been born 13 weeks premature at Stafford Hospital. The twins were moved to a baby unit at the University Hospital of North Staffordshire for specialist care but previous to this, were injected with morphine which was used to stabilise their fragile bodies prior to being transferred.
However, instead of being prescribed the normal 50mg dose of the drug, Alfie was given 600mg and Harry was given 850mg.
Shortly after the error, the twins health began to rapidly deteriorate and two days later they died. An inquest at Cannock Coroners Court heard that the twins cause of death had been lung injuries, bleeding around the brain and other health problems.
It was later revealed that staffing levels on the maternity ward were low and the staff who were present were “inexperienced” and “did not understand” the correct hospital procedures.
The inquest heard that Ami Dean, the twins' mother, was rushed to Stafford Hospital in the early hours of October 30th 2010 after she began to bleed. She gave birth to Alfie at 5.09am and Harry one minute later. The twin boys had both been given the fatal dose of morphine by 7.10am.
It was claimed that uncertainty and confusion between staff over the dilution of the drug resulted in the babies being given too much morphine, which caused oxygen levels in the twins' blood to drop rapidly.
David Field, Professor of neo-natal medicine at Leicester University said, “Staff were inexperienced and didn't quite understand the dilutive procedure… It seems as clear as one can be from the notes that the babies were quite stable, and then there is evidence of instability in both twins. The chances are the babies would have survived if they had not been knocked off course by the morphine, but I can't be sure of that beyond all reasonable doubt.”
A quantity of Naloxone, a drug used to combat morphine overdoses, was made up, but was not administered to the twins as they were stable on a ventilator.
The twins died on November 1st at the University Hospital of North Staffordshire. The cause of the deaths was given as a complication of extreme prematurity.
Doctor Roger Malcolmson, who carried out the post-mortem, said: "From the past history of extremely premature babies, death is likely to have been by natural causes, with an increased risk because they were twins."
Following the tragic incident, a member of staff was suspended and Chief Operating Officer at of Mid Staffordshire NHS Foundation Trust, Maggie Oldham, has launched an internal inquiry.
Police investigated the deaths, but concluded that there was no criminal case.
Miss Dean and Phillip McQuillin, the twins' parents, said that they were “deeply upset and distressed”. The coroner Andrew Haigh will record his verdict on May 23.