Baby C died from a TPN overdose whilst under the care of the Neonatal Unit at Queen Charlotte’s Hospital.
The parents of Baby C have received an apology from the Trust, as well as assurances that measures have been taken to avoid the mistake occurring again.
Suzanne White and Emma Kendall represented the parents of Baby C at the inquest into his death. The Coroner found that there was a ‘systemic failure’ to ensure that the correct equipment to deliver TPN solution to Baby C was used. A severe shortage of volumetric pumps on the Neonatal Unit, coupled with inadequate training and the absence of contingency equipment meant that the solution was delivered using a syringe driver.
The use of syringe drivers to administer TPN was in breach of the policy of the Neonatal Unit, as well as being a breach of the National Patient Safety Alert of 2010. Tragically, the use of the syringe resulted in a significant overdose and Baby C’s death.
Following the inquest, the Trust admitted liability and provided the following apology:
“The Trust’s investigation has found that the care provided to [Baby C] fell below the standard you were entitled to expect and, in particular, that [Baby C] was given an over infusion of Parenteral Nutrition. As part of the inquest process, the Trust has now been provided with a copy of the Post Mortem report and I am extremely saddened to hear that this report concludes that the Trust’s error contributed to [Baby C’s] death.
You have my personal deepest sympathies and I would like to let you know that the Trust’s staff are extremely sorry for the errors that occurred. I appreciate that we will never be able to change the experience you have had and, on behalf of the Trust, I would like to offer you my assurance that the Trust strives to ensure that the quality of its healthcare services continually improves and that the Trust has taken steps to prevent these errors happening again.
I hope that my letter will go some way towards reassuring you that the Trust accepts responsibility for the failings in [Baby C’s] care.”
Partner Suzanne White said:
“The Trust has sent a letter of apology to my clients, which was the right thing to do. However, we cannot forget that Baby C’s death came about because of a breakdown of communication between the staff, and the failure to note that there was a serious shortage of the most basic equipment for these premature babies on the unit. This was a systemic error; I hope sincerely that the Trust have learnt from this terrible tragedy.”
Solicitor Emma Kendall, who assists Suzanne White said:
“Baby C’s parents did not approach Leigh Day because they wanted to obtain monetary compensation from the NHS Trust. They approached us because, like many others in their position, they required representation at the inquest into the death of their child to find out what went wrong. Lawyers play a key role in the inquest process by advocating the concerns of bereaved families (usually against public bodies) and ensuring that a full, thorough and open investigation takes place. If the Government’s proposal to fix costs in ‘low value’ clinical negligence claims comes into force, it will seriously compromise access to justice for families who have suffered a terrible loss such as Baby C’s parents.”