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Tragic death of baby following feeding error.


An inquest has been held following the death of a  seven day old baby after she was given a days worth of food in an hour through a feeding tube.  Maisie Winters fell into cardiac arrest at Bristol Royal Hospital for Children after the nurse mis-programmed the intravenous feeding machine delivering the specially calculated formula known as Total Parental Nutrition. Doctors were unable to revive her despite 45 minutes of CPR.

Laura Bennett, her mother, had previously raised concerns over Maisie’s care, the inquest heard. “They were talking, laughing, joking and paid no attention to the task at hand. They seemed as though they weren’t concentrating.” Maisie was born at Bristol Royal Hospital for Children after a planned caesarean section on the 16th of August 2011 with a condition that meant her heart walls were missing.

The nurse responsible for the error stated that he made the mistake after the machine beeped at him unexpectedly which led him to enter the daily amount of 210ml into the hourly rate, which should have been set at 7.5ml an hour. The amount was 28 times over the stated dose. William Booth, lead Nurse and Matron for paediatric care services at the hospital confirmed at the inquest that the error occurred as a result of incorrect setting of the infusion rate.

The inquest also heard that the hospital did not follow guidelines that required two nurses to double check the rate of infusion despite the fact that two nurses were present when the machine was programmed. Coroner Marie Voisin stated that due to an immediate review of the circumstances leading to Maisie's death and procedural changes that had been implemented it was not necessary to formally suggest changes be made to the hospital.

Maisie’s mother later stated that she had accepted the apology of the nurse responsible for the error, she stated “He came up to us and apologised (after the inquest), which took a lot of courage. At first I was bitter, but now I know his account, I know he didn’t do it intentionally, he just made a mistake, a big mistake.

“We’ll never bring Maisie back and while it’s 10 times worse for us, he’s got to live with it for the rest of his life.” She went on to say “We were robbed of a daughter, granddaughter and great-granddaughter. Hopefully they’ve learnt lessons and nobody else will have to go through this. But, it shouldn’t have taken my daughter dying for measures to be brought in.”

Richard Wood of the CNCI Team commented,  "The main motivations for many of our clients are to secure an apology and ensure that errors cannot be repeated. It does seem in this case that the hospital have changed their procedures and extended a personal apology to the parents. The response of the hospital is to be welcomed but this remains a tragic case, a momentary error resulting in the death of a baby".