A ‘gross failure to provide basic medical care’ and neglect led to the death of an 11-month-old baby in a Surrey hospital, a coroner ruled earlier.
Sophie Burgess was injected with five times the required dose of an anti-seizure drug at St Peter’s Hospital in Chertsey – despite a nurse warning that the amount was both unnecessary and against protocol.
The girl, described her parents as ‘a happy baby, always smiling’, was given a lethal amount of phenytoin in June 2016. She was taken to hospital following a seizure and given the drug. But the child, who had a history of seizures, then vomited, went into cardiac arrest, and died three hours later.
The initial inquest was halted in 2017 to allow for a police investigation, but was resumed last month without any criminal proceedings being brought.
Returning a narrative conclusion at Surrey Coroner’s Court on Wednesday, with a reference that neglect was a contributory factor, assistant coroner Dr Karen Henderson said: ‘I’m satisfied Sophie would not have died when she did if five times the amount of phenytoin had not been administered by the nurses.
‘It was a serious but simple basic error that set Sophie on a path that sadly and devastatingly led to her death.
‘The inexperience of the medical staff, that lay in outdated national policy that did not meet medical standards, contributed to that journey.’
She added: ‘Sophie was in a dependent position, there was a gross failure to provide basic medical care.’
Dr Fiona MacCarthy had requested a correct dosage of 200mg and said it was ‘taken on trust’ that the drug was drawn correctly by two nurses.
However, this was not the case and there was a fatal miscalculation.
The nurses involved could not recall who prepared the medicine, the inquest heard, nor was the dosage checked by the consultant.
The coroner did not find the lack of recall ‘credible’ and said the death ‘was fully caused by phenytoin toxicity’.
She said she would write a Prevention of Future Deaths report explaining the need for medical staff to check the amount of drugs prepared before being administered, particularly when they have the ability to kill.
Dr Henderson also said Ashford and St Peter’s Hospitals NHS Foundation Trust had since conducted an external review and implemented all recommendations.
Sophie’s parents, Gareth and Emma, expressed their disappointment over the coroner’s conclusion.
They said losing their daughter just before her first birthday ‘destroyed the life we knew’.
In an emotional statement read outside the court, they said: ‘We have always known from the outset that what happened to Sophie was preventable and we have had to fight over the last four years to make sure that the mistakes that were made on the day of her death were made known.
‘We wanted to be given a truthful account of what happened on that day and now hope that those responsible will be held accountable.
‘We have had to face essential information being mislaid, altered or not detailed from the events and critical testimony not given in our search for the truth. Our beautiful daughter died and we want to ensure that this can never happen again to another family.
‘We are disappointed with the conclusion of the coroner today, we feel that Sophie’s death was more than neglect and, for Sophie’s sake, we will be pursuing a case to that end.’
Suzanne Rankin, chief executive of Ashford and St Peter’s Hospitals NHS Foundation Trust, said: ‘We are deeply sorry that catastrophic errors in our care led to Sophie’s tragic death.
‘I understand that nothing can take away the pain and grief of Sophie’s death and whilst we sadly cannot change what happened, we want Sophie’s family and other patients and carers to know that we are determined to learn when things go wrong.
‘Since 2016 we have made significant improvements to the administration of phenytoin in all situations to ensure we are doing everything we can to prevent another family suffering in this way. Today our thoughts are with Gareth and Emma Burgess and their family.’
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