Overdose of salt blamed for baby's death

Samuel McIntosh, suffering from breathing difficulties after being born prematurely, died of swelling to the brain following the error at Nottingham's Queen's Medical Centre (QMC) in July last year.

Nottingham Coroner's Court heard that Samuel was wrongly given 50ml of a sodium chloride solution by a nurse, when a registrar had in fact prescribed just 5ml.

Dr Stephen Wardle told the inquest that Samuel, whose parents are from Mansfield, was born at Nottingham's City Hospital on March 1 last year and initially weighed around 580g.

Samuel, who was a sixth of the normal birthweight for a full-term baby, suffered from lung problems and was transferred to the QMC aged 18 days.

Dr Wardle told the inquest that the baby required intravenous feeding and underwent a bowel operation and eye surgery, but his weight eventually rose to 2.8kg and he would have been expected to survive.

But he was taken ill in early July and medics noticed that his sodium levels were low.

Confirming that Samuel was then given 10 times the correct concentration of sodium chloride, Dr Wardle said rapid changes in sodium levels could cause swelling to the brain.

When he was born prematurely, he weighed 1lbs 4oz (580g) – about a sixth of the normal weight for a full-term baby.

Reaching his verdict, Dr Chapman said there was no doubt that a dreadful mistake had taken place, but ruled that it did not fall into the category of a gross failure.

In a statement issued by Nottingham University Hospitals NHS Trust, its medical director, Dr Stephen Fowlie, apologised unreservedly for the failings in care which resulted in Samuel's death.

Dr Fowlie said: "Our investigation, which included an external expert, identified that a fatal mistake in giving a salt solution caused Sam's death.

"An undiluted solution was given and Sam received 10 times more salt than he should have done."

New guidance has now been brought in to minimise the need for concentrated salt solution, infusion prescription charts on the neonatal unit have been changed, and a system has been brought in to ensure nurses are not interrupted when administering drugs.

Dr Fowlie concluded: "We have remained in contact with Sam's parents throughout the investigation and have met with them on several occasions.

"We appreciate that we cannot change what happened or compensate for the loss of their baby, and we are determined there will be no repeat of our mistakes."