An 11-month-old girl who died in hospital was let down by “a gross failure to provide basic medical care” after being injected with five times the required dose of an anti-seizure drug, a coroner has ruled.
Sophie Burgess was given a lethal amount of phenytoin, despite the protestations of a nurse who said it was both unnecessary and against protocol.
A police investigation led to no charges being made, with the inquest finding neglect was a contributory factor, as well as “outdated national policy”.
Sophie’s parents, Gareth and Emma Burgess, said they were disappointed with the coroner’s conclusion and they hoped “those responsible will be held accountable”.
“We feel that Sophie’s death was more than neglect and, for Sophie’s sake, we will be pursuing a case to that end,” they added.
Sophie had initially been taken to St Peter’s Hospital in Chertsey following a seizure, for which she was given phenytoin.
The consultant requested a correct dosage of 200mg and said it was “taken on trust” the drug was drawn correctly by two nurses.
However, it was discovered that 1,000mg of undiluted phenytoin was drawn up into the syringe – more than five times the recommended dose.
The child, described by her parents as “a happy baby, always smiling”, vomited, went into cardiac arrest, and died three hours later.
The nurses involved could not recall who prepared the medicine, the inquest heard, nor was the dosage checked by the consultant.
The initial inquest was halted in 2017 to allow for a police investigation, but was resumed last month without 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 it is basic medical care to be able to calculate and confirm the correct amount of phenytoin and that both nurses are jointly responsible for those miscalculations which, sadly, had catastrophic consequences for Sophie.
“If this error had not been made, Sophie would not have died when she did.
“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“The inexperience of the medical staff, that lay in outdated national policy that did not meet medical standards, contributed to that journey.”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.”
The coroner 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.
She also said Ashford and St Peter’s Hospitals NHS Foundation Trust had since conducted an external review and implemented all recommendations.
In a statement issued by law firm Leigh Day, the tragic baby’s parents said: “Sophie was the delight of our lives, we loved her with all of our hearts and not a day goes by without her in our thoughts.
“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.
Mr and Mrs Burgess also said: “Sophie was a bright and happy child, always laughing and smiling. She was a joy to be around and made our family complete.
“Losing her suddenly, in this way, just before her first birthday, destroyed the life we knew.
“When Sophie was taken to St Peter’s Hospital, we thought she would be safe and well cared for. Instead, we watched her die, due to their multiple failures.
“The pain of her death will never leave us and we grieve for her every day,” they added.