'Distracted' nurses' drug error killed baby 25 November, 2010 | By The Press Association 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 coroners court heard that Samuel McIntosh died at the citys Queens Medical Centre (QMC) in July last year after being given 10 times the prescribed dose of sodium chloride. 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 Samuels low salt levels. The Nottingham coroner, Dr Nigel Chapman, was urged by the solicitor acting for Samuels 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 dont 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. http://www.nursingtimes.net/nursing-practice/clinicalspecialisms/management/distracted-nurses-drug-error-killed-baby/5022406.article

Nurse suspended after 'young at heart' grandmother, 80, killed by massive overdose of medication A grandmother being treated in hospital for a mild case of pneumonia died after accidentally being given a lethal injection. Police chief's widow Arsula Sansom, 80, was given an infusion of potentially dangerous potassium at ten times the correct rate after becoming breathless. Within minutes she suffered a heart attack, and doctors were unable to revive her. The nurse whose blunder led to the drug being administered too quickly was suspended while an investigation was carried out into Mrs Sansom's death, but her grieving family have not been given the results. Yesterday the family said that they were convinced she would still be alive had it not been for the error on Mother's Day this year and that they had lost faith in the NHS. Mrs Sansom's daughter Bonnie Hughes, 55, said her mother had remained 'young at heart'. She enjoyed shopping trips for jewellery or designer clothes and until recently drove a sports car. Even after her admission to NHS Good Hope Hospital in Sutton Coldfield, West Midlands - only her second trip to hospital since the birth of her youngest child 36 years ago - Mrs Sansom remained in good spirits, making light-hearted quips to relatives. 'It wasn't Mum's time to go,' said Mrs Hughes, a civil service manager. 'Just the night before she died she was joking with the family, asking people to bring her some rollerskates.' 'If the trust is understaffed and making mistakes, it must be open. It must put its hands up - and this treatment has got to be stopped. It's just another case of the critical state the NHS is in.' 'Although she wasn't made to last forever, I feel she would have pulled through this. Now we'll never know.' Mrs Sansom led a glamorous international lifestyle along with her late husband, Douglas. He worked as a managing director at British Leyland before joining the Hong Kong police as a senior officer in charge of its vehicle fleet, while she was active in amateur dramatics productions. When he died following a heart transplant operation in 1990, she moved back to Sutton Coldfield to be closer to her four daughters where she continued to be a feisty character who made the most of life. 'My mother drove sports cars, absolutely loved them,' said her daughter. 'She lived independently and was always dressed glamorously and was perfectly made-up.' 'We were always going shopping together and we saw each other every other day with my sister.' On March 9 the grandmother-of-eight reluctantly allowed herself to be admitted to hospital after being diagnosed with a suspected urinary tract infection. The following day she developed mild pneumonia and was moved to the high dependency unit, but by the 13th her family found her 'lively and in high spirits'.But at 6.15am on March 14, when she appeared to be breathless, a nurse was instructed to administer an infusion of potassium to increase her oxygen levels. Within minutes she had a heart attack and efforts to revive her failed.

Inquiries revealed Mrs Sansom - 5ft 6in tall and weighing less than seven stone - had been given the infusion over a 30-minute period rather than the recommended five hours - giving her ten times the correct dose. Doctors told her family the nurse had pressed the button too many times, and she has been suspended.'I was given no explanation as to how this could have happened,' her daughter said. 'We just couldn't believe it.' Potassium administration rules dictates that a doctor should supervise its administration. In addition, the family have discovered Mrs Sansom was suffering from chronic renal disease which they claim meant she shouldn't have been given potassium anyway. The Heart of England NHS Trust said it had carried out a 'serious untoward incident' investigation into the overdose which was being passed to the coroner who will hold an inquest at a later date and could therefore not release its findings. 'We would like to again pass on our sincere condolences to the family,' added a spokesman. http://www.dailymail.co.uk/news/article-1288631/Sutton-Coldfield-grandmother-80-killedhospital-error.html

May 18, 2010 Hospital is fined 100,000 over death of mother in drugs mix-up David Sanderson A hospital trust that was fined 100,000 yesterday after a new mother died because of a mix-up between identical-looking drugs has apologised to her family. Mayra Cabrera died hours after her son Zac was born when a nurse at the Great Western Hospital in Swindon, Wiltshire, wrongly attached an epidural anaesthetic Bupivacaine to her intravenous drip instead of a saline solution. Mrs Cabrera, 30, who was a nurse at the same hospital, died within minutes. Her son survived. Bristol Crown Court was told that the two drugs, which had similar packaging, were stored in the same cupboard, contrary to best practice. Fining Great Western Hospitals NHS Trust 75,000 and ordering it to pay 25,000 costs, Mr Justice Clarke said that the tragedy in May 2004 arose because of systematic and individual fault. An inquest at Trowbridge, Wiltshire, two years ago, which ruled that Mrs Cabrera was unlawfully killed, also cited the chaotic drug storage. The Crown Prosecution Service did not bring charges against Marie To, the midwife. She was suspended and has since retired. The Health and Safety Executive (HSE), which brought the prosecution, said the heartbreaking case showed that there was no proper system for the storage of the drugs at the time. A similar mistake in 2001, which did not result in death, had not served as a sufficient warning. Liam Osborne, an HSE inspector, said: Mayra Cabrera needlessly died as a result of comprehensive management failings at board, pharmacy and ward level. Had the hospital done something as simple as keeping these completely different but almost identical-looking drugs in separate cupboards, then Mrs Cabrera would not have died. Lyn Hill-Tout, chief executive of the trust, which pleaded guilty to an offence under the Health and Safety at Work Act, apologised for the mistakes. She said: As a result of what happened, a husband does not have a wife and a son does not have a mother. We deeply regret this. Mayras death should not have happened. Regrettably, we cannot turn the clock back. However, we have learnt valuable lessons and will never again be complacent about patient safety by ensuring it remains our top priority at all times. Arnel Cabrera, Mrs Cabreras widower, who has now returned to their native Philippines with their son, said in a statement that he was pleased with the outcome. He added: It reinforced the importance of the heath and safety of patients attending hospital and in particular the safe storage of dangerous drugs. Now this case has concluded, I am hoping my young son and I can have some closure and put this terrible tragedy behind us. Earlier Barry Cotter, defending the trust, told the court that its attitude was far from cavalier or lethargic and, given that more than one million infusions were carried out each year, a blind spot would arise on occasion. Mrs Cabreras month-long inquest in 2008 was told how the hospitals storage methods failed to meet NHS requirements. It was stated that drugs such as Bupivacaine should be stored in locked cupboards separately from intravenous fluids. There had been two other deaths at hospitals in the UK in the past decade caused by Bupivacaine being administered intravenously, the coroner David Masters was told.

Soon after one that of 74-year-old Philip Silsbury in 2001 at Royal Sussex County Hospital a memo was sent round Swindon & Marlborough NHS Trust advising that Bupivacaine be kept separately from intravenous drugs to lessen the chance of a mixup. At the time the hospital was at its old Princess Margaret Hospital site in Swindon before its move to Great Western Hospital in December 2002. Stephen Holmes, the now-retired chief pharmacist at Great Western, sent the memo on correct Bupivacaine storage around the Princess Margaret Hospital in 2001. He was told at the time by staff that this had in fact been the hospitals practice since 1995. However, these storage standards were not carried over to the new Great Western site, with epidural drugs stored alongside intravenous ones. It was not until after Mrs Cabreras death that drug storage was brought up to standard. http://www.timesonline.co.uk/tol/news/uk/health/article7129219.ece