Two newborns died after ‘complete and total failure’ by hospital, which led to serious ‘medication error’

TWO babies born prematurely died just weeks apart after hospital staff administered the wrong medication, the inquest jury heard.

Little Elena Ali and Sunny Parker-Propst were given sodium nitrite instead of baking soda while being cared for at Chelsea and Westminster Hospital in 2020.

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On Monday, the jury returned verdicts of unlawful killing caused by the neglect of baby Sunny and accidental death caused by the neglect of baby Elena.

Lesley Watts, from Chelsea and Westminster Hospital NHS Foundation Trust, said: “We apologize unreservedly for the failings in the care provided to Elena and Sunny.”

She added: “We have taken immediate steps to implement measures to prevent such tragic incidents from happening again.”

Neither the pharmacist responsible for the medicines given to the babies nor the nurse looking after them checked whether the medicine was correct, the inquest heard.

Elena was born prematurely on April 16, 2020 and her condition was classified as moderate, so she was stabilized in the delivery room.

Two days later, her blood gas was measured during routine monitoring, which showed she had too much acid in her blood, known as metabolic acidosis.

The condition can be fatal if not treated properly.

You have been prescribed an infusion of sodium bicarbonate, which can be used to balance acids in your blood.

But instead, the baby was accidentally given sodium nitrite, causing her to die later that day.

Sunny was born prematurely two weeks later, on April 30, and was transferred to the neonatal intensive care unit (NICU) for continued care.

Like Elena, he was given a sodium bicarbonate infusion after tests showed he suffered from metabolic acidosis.

However, he received sodium nitrite by mistake after it was incorrectly stored in the NICU and selected and administered by the nursing staff.

He died on May 9.

I DIDN’T MAKE ADEQUATE CHECKS

The coroner said the hospital’s chief pharmacist admitted there was a “complete and total” failure of checks inside the pharmacy.

This led to the issuance of a box of sodium nitrite instead of sodium bicarbonate.

Internal investigations within the pharmacy were unable to identify who had issued the wrong medication, the inquiry was told.

The unit’s neonatal nurse coordinator told the inquiry that she was aware of a policy of checking the bottles, collecting them and looking at them at eye level – but that she did not do so.

She accepted that these are fundamental steps to take and that if she had taken them she would have realized it was sodium nitrate.

‘I MISS HIM EVERY DAY’

Selina Mazumder, Elena’s mother, said: “There are a lot of mixed emotions, it has taken four long years to get to this point.

“We believe that the conclusions the jury reached today reflect our own feelings and what we have always known.

“What is the catalog of failures that were really serious and negligent and that both Elena and Sunny lost their lives because of those failures and that they should be here today.”

Kerstin Propst, Sunny’s mother, said: “I’m happy that this inquest process has finally allowed us to get some answers about what happened to our beloved Sunny, although it has been great to hear about the multiple failures and missed opportunities that led to his tragic death. difficult to hear.

“Losing Sunny needlessly completely destroyed the entire family, not just me.

“He will always mean a lot to me and I am very proud of him. I miss him every day.”

‘SHOCKING’

The families were represented at the inquest by solicitor Frankie Rhodes, of law firm Leigh Day.

Ms Rhodes said the verdict would give the families “some closure” but highlighted a “catalogue of mistakes and basic failings by the nurses involved in the care of both babies”.

“It is shocking that these premature babies, some of the most vulnerable in society, have been put at risk, and both Elena and Sunny have needlessly lost their lives due to failures to carry out simple checks that are a fundamental part of the work of a neonatal nurse. ” she said.

The ten-day inquest was held at Westminster Coroners’ Court by senior coroner for Inner West London, Prof Fiona Wilcox.

What is metabolic acidosis?

Metabolic acidosis is a condition that occurs when there is too much acid in the body’s fluids

This can happen when the body produces too much acid or when the kidneys cannot remove enough acid.

Some causes of metabolic acidosis include:

• Untreated diabetes: also known as diabetic ketoacidosis (DKA), occurs when ketone bodies accumulate during uncontrolled diabetes
• Kidney conditions: People with chronic kidney disease (CKD) are at greater risk of developing metabolic acidosis, especially in more advanced stages
• Bicarbonate loss: This can be caused by severe diarrhea or laxative abuse

In newborns, the condition may be a sign of other underlying health problems, such as hypoxemia., hypotension or poor tissue perfusion, anemia, infection or sepsis, or strenuous activity (difficulty breathing).

Symptoms of metabolic acidosis include:

Rapid breathing, rapid heartbeat, headache, confusion, weakness, fatigue, loss of appetite, nausea, vomiting and fruity-smelling breath.

Blood and urine tests can help diagnose metabolic acidosis, and treatments may include sodium bicarbonate, intravenous fluids, and insulin.

Treatment:

Treatments for metabolic acidosis depend on the cause of the acid-base imbalance. Some common treatments include:

• Nutrition: Eat more fruits, vegetables and plant-based proteins and less meat, egg yolks, hard cheeses and grains
• MedicationsTake sodium bicarbonate, sodium citrate, potassium citrate, or other medications prescribed by your doctor
• FluidsReceive intravenous fluids or drink plenty of water and non-alcoholic fluids
• Other treatments: Depending on the type of metabolic acidosis, treatments may also include insulin, oxygen, antibiotics, or detoxification.

Source: Cleveland Clinic + Sydney Local Health District