THE GRIEVING parents of twin baby boys who died after being given a morphine overdose at Stafford Hospital must wait until next week to hear a coroner’s decision.
The inquest into the deaths of Alfie and Harry McQuillan heard the infants were given more than 10 times too much of the controlled drug after being born 13 weeks premature.
Medical staff had to read the hospital protocol for administering morphine to babies before the tots were give the drug by a nurse – Lisa Lucas - who had never given it to babies before.
The infusion was given to Harry at 6.50am on October 30 with Alfie given his dose 20 minutes later, less than two hours after they were born.
They had been delivered by Cesarian section after their mother Ami Dean, of Marston Road, Stafford, started bleeding and was taken to the town hospital by ambulance.
Nurse Lucas told the inquest in Stafford she noticed the babies were having problems at about 7.30am.
She said senior staff nurse Joanne Thompson had been adamant they had used the correct procedure and it was another nurse starting a day shift who spotted the error.
“I can’t forgive myself for not checking the treatment sheet harder,” said Nurse Lucas.
“We missed it and I don’t know how we missed it.”
A Home Office pathologist found the twins were both suffering from lung disease and bleeding to the brain.
Professor David Field, who investigated the deaths, said the Stafford unit was not geared to deal with such a case and had the twins not been given the morphine overdose they would have survived.
“At 7am these babies looked in pretty good shape but within a few hours they had deteriorated,” he said.
“The start of that deterioration was when they had this overdose.”
The twins were transferred to University Hospital of North Staffordshire but died on November 1.
Sister Gina Hartwell, special care baby unit manager who was not involved in the care of the babies, blamed human error for the mistake, saying there was “no immediate need to give the morphine.”
In her statement which was read to the court, she said: “This was the direct result of human error. The correct procedure was not followed.”
South Staffordshire coroner Andrew Haigh will give his decision on Wednesday (May 23).