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Toddler died after being given 'seven times correct dose' of drug Child died after being given 'seven times correct dose' of drug
(about 3 hours later)
A toddler died after being given an overdose of medication by staff at a hospital, a coroner has ruled.A toddler died after being given an overdose of medication by staff at a hospital, a coroner has ruled.
Jake Stanley, 3, suffered a cardiac arrest after a breakdown in communication led to a doctor giving him seven times the correct dose of an anti-seizure drug. Jake Stanley, 3, went into cardiac arrest after a breakdown in communication led to a doctor giving him seven times the correct dose of an anti-seizure drug.
Jake had arrived at Whiston hospital, near St Helens in Merseyside, after having two seizures in January 2017, and was on a ventilator.Jake had arrived at Whiston hospital, near St Helens in Merseyside, after having two seizures in January 2017, and was on a ventilator.
An inquest at St Helens was told that Dr Thomas Whitby had administered the undiluted phenytoin to prevent more seizures but did not discuss a dose with the staff nurse, Tony Mulcahy. The nurse prepared the medication while Dr Whitby was out of the room and did not label it, the inquest was told. Dr Whitby said he believed the dosage was correct. An inquest at St Helens was told that Dr Thomas Whitby had administered the undiluted phenytoin to prevent more seizures but did not discuss a dose with the staff nurse Tony Mulcahy. The nurse prepared the medication while Whitby was out of the room and did not label it, the inquest was told. Whitby said he believed the dosage was correct.
Jake went into cardiac arrest after being injected at 6.30pm on 21 January and was declared dead at 7.16pm.Jake went into cardiac arrest after being injected at 6.30pm on 21 January and was declared dead at 7.16pm.
A postmortem and reports by forensic experts found that Jake was given an overdose of phenytoin at seven times the intended rate and seven times the intended dose, the inquest heard. A postmortem and reports by forensic experts found that the child was given an overdose of phenytoin at seven times the intended rate and seven times the intended dose, the inquest heard.
The senior coroner Christopher Summer concluded there was a gross failure to provide, among other things, basic medical attention to Jake and that this caused his death. The senior coroner Christopher Summer said there was a gross failure to provide, among other things, basic medical attention to Jake and that this caused his death.
A medical expert told how the concentration of the drug in his blood was consistent with fatalities. A medical expert told how the concentration of the drug in the boy’s blood was consistent with fatalities.
The coroner concluded that his death was brought about by neglect.The coroner concluded that his death was brought about by neglect.
He said: “There was a total breakdown in communication in the period that Jake received the drug and confusion as to dosage, concentration and means of administering it, amounting to neglect. Hospital protocols were breached, causing the overdose and subsequent death of Jake. By his own admission, nurse Mulcahy did not follow protocols and have another nurse check the contents of the syringe, an omission [made], it would appear, not for the first time.” Summer said: “There was a total breakdown in communication in the period that Jake received the drug and confusion as to dosage, concentration and means of administering it, amounting to neglect. Hospital protocols were breached, causing the overdose and subsequent death of Jake. By his own admission, Nurse Mulcahy did not follow protocols and have another nurse check the contents of the syringe, an omission [made], it would appear, not for the first time.”
The cause of death was recorded as a combination of medication overdose, a fever-like convulsion and a brain malformation.The cause of death was recorded as a combination of medication overdose, a fever-like convulsion and a brain malformation.
Stanley’s parents, Anne-Marie and Ian Stanley, said: “Our son Jake was the most amazing little boy who had his whole life ahead of him. The boy’s parents, Anne-Marie and Ian Stanley, said: “Our son Jake was the most amazing little boy who had his whole life ahead of him. He was always happy and smiling. He brought so much joy and happiness into the lives of everyone who met him.
“He was always happy and smiling. He brought so much joy and happiness into the lives of everyone who met him.
“We could not have been any more proud of the wonderful little boy that he came to be in the three short years that he was with us and it truly is saddening to know that Jake’s baby brother will never get the chance to know first-hand just how much his big brother loved him.”“We could not have been any more proud of the wonderful little boy that he came to be in the three short years that he was with us and it truly is saddening to know that Jake’s baby brother will never get the chance to know first-hand just how much his big brother loved him.”
The St Helens and Knowsley Teaching Hospitals NHS Trust offered condolences and said: “When Jake arrived at the hospital he was extremely poorly and required intensive support.” St Helens and Knowsley teaching hospitals NHS trust offered condolences and said: “When Jake arrived at the hospital he was extremely poorly and required intensive support.”
The trust has carried out an investigation and concluded that medicine protocols had not been followed.The trust has carried out an investigation and concluded that medicine protocols had not been followed.
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