Premature baby given massive drug overdose at Leeds hospital
A premature baby was given a drug overdose 10 times the correct level – 10 times in 48 hours – at a Leeds hospital.
Kyle Thistlewaite, right, was born at Leeds General Infirmary prematurely, at just 25 weeks and five days.
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And on 10 occasions he was given a steroid to improve his low blood pressure that was 10 times the recommended dosage, before the error was spotted.
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Three days into his life, the baby was dead. An inquest at Leeds Coroner's Court found the error did not cause his death.
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But West Yorkshire Coroner David Hinchliff highlighted the mistake as he recorded the cause of death as intraventricular haemorrhage – bleeding in the brain, coupled with the baby's extreme prematurity.
He said: "It's highly likely that Kyle has died from the inevitable consequences of his extreme prematurity and that the drug error has not played a part in his death."
Kyle's father Craig Thistlewaite said: "We were horrified to learn of the dosage error given to Kyle but we are relieved to find out that this did not contribute to his death."
He added: "How a baby can be given an overdose so high in the first place is bad but to be given the overdose 10 times is totally unacceptable."
He said: "We welcome any further action to stop mistakes like this happening again as we wouldn't want anyone to suffer the pain we have."
Leeds Coroner's Court heard Kyle was born on April 20 2007 after his mother Francesca was transferred from Bassetlaw Hospital in Worksop.
At one day old, in the Neonatal Intensive Care Unit, he developed profound circulatory failure.
The coroner's narrative verdict said doctors prescribed intravenous hydrocortisone but "due to a prescribing error he received 10 times the intended dose, on 10 occasions, over the next 48 hours".
He died on April 23 after suffering the most serious form of intraventricular haemorrhage and pulmonary haemorrhage – bleeding in the lungs
Tim Annett, medical law specialist from Irwin Mitchell, representing the family, said the case raised serious concerns about hospital procedures.
Mr Annett said: "Kyle's parents want to make sure that this can never happen again."
He added: "Patient safety should be the number-one concern of the NHS and it is vital that improvements are identified and implemented to stop what is essentially a very basic error."
A spokesman for Leeds Teaching Hospitals NHS Trust said extra safeguards and training had been introduced to reduce the chance of such an error happening again.
He added: "The Coroner made clear he was satisfied that the Trust had appropriate systems in place to try and minimise prescription errors, but in this instance human error resulted in a mistake being made."
He said Mr Hinchliff as satisfied the Trust had taken appropriate steps to address what had happened.
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Friday 25 May 2012
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