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Toddler died after medication error.

A toddler died after being given an overdose of medication by staff at a Merseyside hospital, a coroner has ruled.

Jake Stanley, 3, went into cardiac arrest after a breakdown in communication led to a doctor giving him seven times the correct dose of an anti-seizure drug.

Jake had arrived at Whiston hospital, near St Helens, after having two seizures in January 2017, and was on a ventilator.

An inquest at St Helens was told that Dr Thomas Whitby had administered the undiluted phenytoin to prevent more seizures but did not discuss an appropriate dose with the staff nurse, Tony Mulcahy, who had prepared the dose.

The nurse prepared the medication while Dr Whitby was out of the room and did not label it, the inquest heard. Dr Whitby said he believed the dosage was correct.

The child went into cardiac arrest after being injected at 6.30pm on 21 January and was declared dead at 7.16pm.

A postmortem and forensic reports found that the child was given an overdose of phenytoin, at seven times the intended rate, and seven times the intended dose, the inquest was told.

The senior coroner, Christopher Summer, said Jake Stanley died after there was a gross failure to provide basic medical attention and concluded that his death was brought about by neglect.

A medical expert told how the concentration of the drug in the boy’s blood was consistent with fatalities.

Christopher Summer said: “There was a total breakdown in communication in the period that Jake received the drug and confusion as to dosage, concentration and means of administering it, amounting to neglect.

“Hospital protocols were breached, causing the overdose and Jake’s subsequent death. By his own admission, nurse Mulcahy did not follow protocols and have another nurse check the contents of the syringe.”

The cause of death was recorded as a combination of medication overdose, a fever-like convulsion and a brain malformation.

The boy’s parents, Anne-Marie and Ian Stanley, said: “Our son Jake was the most amazing little boy who had his whole life ahead of him. He was always happy and smiling. He brought so much joy and happiness into the lives of everyone who met him.

“We could not have been any more proud of the wonderful little boy that he came to be in the three short years that he was with us. It is truly is saddening to know that Jake’s baby brother will never get the chance to know first-hand just how much his big brother loved him.”

St Helens and Knowsley teaching hospitals NHS trust offered condolences and said: “When Jake arrived at the hospital he was extremely poorly and required intensive support.”

An investigation by the trust concluded that medicine protocols had not been followed.

 

 

 

 

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