Family of dead boy in tears as doctor admits: I made mistake

Dr Helen Moore asked the coroner if she could make a short statement when she gave evidence at the inquest yesterday into the death of Bailey Ratcliffe at Dewsbury and District Hospital in 2009.

Bailey was epileptic and was brought into the hospital’s accident and emergency department suffering the worst fit his family had ever experienced.

Bradford Coroners’ Court heard how he was given the drug phenytoin on the orders of Dr Moore, a paediatric registrar called to help deal with the youngster’s life-threatening condition.

Before giving details of what happened, the doctor turned to Bailey’s mother Carrianne Ratcliffe and said: “I just wanted to say it’s with tremendous sorrow I find myself here today.”

Dr Moore said this was not only for mistakes that were made but also for the fact it had taken “three-and-a-half years to see you face-to-face and say how sincerely sorry I am for these mistakes”.

Ms Ratcliffe and other members of her family were in tears as the doctor made the apology.

Bradford Coroner Peter Straker heard how Bailey had been fitting for three hours when he arrived at the hospital on May 27, 2009.

Dr Moore described how he had been given other drugs by his family, paramedics and A&E staff to try and control the fitting but she decided it was time to move on to phenytoin.

The doctor admitted, however, she made a mistake in the dosage instructions when she asked a junior doctor to prescribe the drug.

Dr Moore told the court she thought she got confused in her mind with the procedures for administering a different drug used in cases of severe asthma, telling the hearing “I just made a mistake”.

She wrongly asked for a prescription for the drug to be drawn up in a loading dose, to be applied first, and then a follow-up maintenance dose – a continuing infusion over a large period of 
time – which was applied shortly after.

She agreed she was confused by the “administration rate of the drug and the dose”.

“I just got confused. I don’t know why – on this day, at that time.”

The prescription was written by a junior doctor, drawn up a by a nurse and initialled by another junior doctor.

After initially attending to Bailey, Dr Moore left to carry out other duties and was called back to treat him at around 4pm when he had stopped breathing.

A full resuscitation team was called in but it could not save his life and he was pronounced dead at around 5.30pm.

Under questioning from the coroner, Dr Moore said it had been a very busy day as she was the only paediatric registrar on duty.

She said it was “a day that had some stress elements, a lot going on I needed to try and cover”.

Her department was already dealing with premature twins which were causing concern when Bailey was brought in.

She said her consultant stayed with the twins and was not involved with Bailey in the accident and emergency department.

Dr Moore added: “If I ever make a mistake I want to know about it so we don’t cause the trauma we’ve caused today.”

Pathologist Professor Philip Batman told the court Bailey’s cause of death was phenytoin toxicity complicated by his epilepsy.

Toxicologist Richard Sykes told the hearing the level of phenytoin in his blood was “considerably excessive” and at least six times the maximum amount.

The inquest continues and is 
expected to finish later this 
week.