Parents vow to take legal action over death of 11-month-old daughter as coroner blasts blasts medics’ ‘gross failure to provide basic care’ for giving her five times the right dose of anti-seizure drug

  • Sophie Burgess given a lethal amount of anti-seizure drug, five times right dose
  • The 11-month baby vomited, went into cardiac arrest and died three hours later 
  • Today, a coroner ruled that baby Sophie was let down by ‘gross failure’ of medics
  • Her parents have vowed to take legal action following the coroner’s ruling today 

The parents of an 11-month-old girl who died in hospital after she was let down by ‘a gross failure to provide basic medical care’ and injected with five times the required dose of an anti-seizure drug have vowed to take legal action.

Sophie Burgess was given a lethal amount of phenytoin, despite the complaints of a nurse who said it was both unnecessary and against protocol.

The baby had initially been taken to St Peter’s Hospital in Chertsey, Surrey on June 16 2016 following a seizure, for which she was given phenytoin.

But the child, described by her parents as ‘a happy baby, always smiling’, vomited, went into cardiac arrest, and died three hours later.

The initial inquest was halted in 2017 to allow for a police investigation, but was resumed last month without criminal proceedings being brought.

Speaking outside the inquest, Sophie’s mother and father said they believed their daughter’s death was ‘more than neglect’ and vowed to prove that in a separate court. 

Eleven-month-old Sophie Burgess died after being given the drug phenytoin in hospital 

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 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‘The inexperience of the medical staff, that lay in outdated national policy that did not meet medical standards, contributed to that journey.’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.’ 

Gareth and Emma Burgess, who lived in Chertsey, 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.

Dr Fiona MacCarthy attempted to inject baby Sophie with the drug at the Surrey hospital

‘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.

‘We are disappointed with the conclusion of the coroner today, we feel that Sophie’s death was more than neglect and, for Sophie’s sake, we will be pursuing a case to that end.’

The nurses involved could not recall who prepared the medicine, the inquest heard, nor was the dosage checked by the consultant.

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.

Caroline Pearson-Smith who died in 2016 after being prescribed ten times the normal dose. The coroner ruled that there had been gross failures in her care also

She also said Ashford and St Peter’s Hospitals NHS Foundation Trust had since conducted an external review and implemented all recommendations.

The family solicitor, Leigh Day partner Suzanne White, who also represented the family of Ms Pearson-Smith, said: ‘It is unacceptable that Sophie’s parents have had to wait four years for the investigative process into their daughter’s tragic death to run its course. Emma and Gareth deserve answers about what has gone wrong in the police and coronial procedures for these delays to happen.

‘Secondly, Sophie’s is another unnecessary death at St Peter’s Hospital, Chertsey as a result of an overdose of the anti-seizure drug Phenytoin. In the case of Caroline Pearson-Smith, the coroner ruled that there had been gross failures in her care. Clearly something is amiss in the use of this drug by the Ashford and St Peter’s Hospitals NHS Foundation Trust.’

Little Sophie had been rushed to hospital after attending was described as ‘alert and crying’ shortly before Dr Fiona MacCarthy took the decision to manually inject her with Phenytoin, 200mg of which should have been administered evenly over 20 minutes on June 16 2016, the inquest heard.

Dr MacCarthy ordered the junior doctor, Dr Lojein Hatahet to prescribe and physically inject Sophie with Phenytoin.

Nurse Sharron Younas and nurse Polly Leavald went to draw up the Phenytoin but made a mistake while drawing up the drug

Dr Henderson, sitting at Woking Coroner’s Court in Surrey, said: ‘Both nurses indicated they were experienced with the preparation of Phenytoin and had done so beforehand. However neither nurse could recall who drew up the Phenytoin, who signed and countersigned it on the drug chart, how many vials were drawn up or the precise size of the syringe used to prepare the Phenytoin infusion.

‘Given the experience both nurses purported to have, I do not find their lack of recall of those details credible.’

The inquest found that nurses had provided Dr MacCarthy with a syringe containing 1,000mg of the drug, after misreading the labels on the bottles in the hospital, an expert told the inquest.

By 1.10pm, when the medics gave Sophie the Phenytoin, she was stable and sleepy, having been given 5mg of diazopam and antibiotics, the inquest heard, such that she had been moved from the resuscitation area to the paediatric ward.

‘While Phenytoin was being administered, Sophie was seen to gag and vomit, following which she had a seizure and shortly thereafter a cardio-respiratory arrest,’ Dr Henderson told the hearing.

Medics had continued to give Sophie the Phenytoin manually, as the syringe driver they had tried to use had been ‘alarming’ because there was too much pressure, the inquest heard.

Dr Mohammed Rahman, a paediatric consultant who had been practicing for 20 years, was called as an expert witness and told the inquest he had never seen Phenytoin being given manually because it is difficult to ensure it is given at the correct rate.

Dr Henderson decided Dr MacCarthy, who had no experience of giving Phenytoin manually, should not have ordered the Phenytoin to be given at that time as the baby was no longer in status epilepticus and said it was the consultant paediatrician’s ‘inexperience’ which led to the decision.

The coroner said: ‘Whilst I accept that it is not unreasonable to give Phenytoin, I accept that the administration of it when it was given was not time-critical. It did not need to be given at the time it was given.

‘Inexperience and perhaps more importantly a lack of understanding of that inexperience by the consultant paediatrician has played a large part in the decision of the peadiatric consultant to give Phenytoin at the time it was given and indeed how it was given.

‘I accept this inexperience would not have been obvious if the correct concentration had been prepared, however, it showed itself because the correct dose was not prepared and as such I am satisfied that inexperience on behalf of the consultant paediatrician and a lack of understanding of the inexperience and also to a lesser extent the paediatric trainee, played a more than minimal role in Sophie’s death.’

The inquest had heard how nurse Leavald refused to give the Phenytoin and protested that it was against hospital policy to give it manually.

Representatives from the Ashford and St Peter’s NHS Trust confirmed that at the time of Sophie’s death Phenytoin was given ‘neat’ rather than undiluted at the St Peter’s Hospital.

After the baby’s death, an investigation found three of the other consultant paediatricians who were working at the hospital had said they did not know Phenytoin was to be given neat at the St Peter’s Hospital, where bottles were labelled ‘NOT FOR DILUTION’.

The coroner made a finding that Sophie had died from ‘Phenytoin toxicity contributed to by neglect.’

Dr Henderson said: ‘What happened to Sophie was terrible. I have not doubt about it. The anguish and distress of the family cannot be underestimated and forgotten and it will not be, but I am satisfied that there was not one action by the nurses and medical staff that reached the very high bar required to record such a conclusion.

‘It was at the very heart a serious but simple basic calculation error that set Sophie on the path that sadly and devastatingly led to her death and that inexperience of the medical staff within the hospital system that had an outdated policy on the administration of Phenytoin that did not meet national standards also contributed to that dreadful journey.

‘It is all these elements that collectively rather than individually caused Sophie’s death. Sophie was in a dependent position, there was a gross failure to provide basic medical care.’

Sophie’s medical cause of death was given as 1(a) cardiorespiratory arrest, 1(b) Phenytoin toxicity, 2(a) A-typical epyleptical seizures and viral respiratory tract infection.

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