Two premature babies died weeks apart at a London hospital after being given the wrong drug, an inquest jury has found.
Elena Ali and Sunny Parker-Propst were given sodium nitrite instead of sodium bicarbonate while receiving treatment at Chelsea and Westminster Hospital in 2020.
Westminster Coroner’s Court heard how Elena was born prematurely on April 16, 2020 and her condition was classed as moderate, so she was stabilised on the delivery suite.
Two days later, her blood gas was taken during routine monitoring which showed she had too much acid in her blood, for which she was prescribed a sodium bicarbonate infusion.
The inquest heard that Elena was given a sodium nitrite infusion in error, causing her to die later that day.
Sunny was born prematurely on April 30, 2020 and transferred to the neonatal intensive care unit (NICU) for continuing care. Like Elena, he was prescribed a sodium bicarbonate infusion after tests revealed there was too much acid in his blood.
However, he was given sodium nitrite in error after it was wrongly stocked on NICU and selected and administered by nursing staff. Multiple staff failed to recognise that the wrong drug was being given, the inquest heard.
Sunny died on May 9.
On Monday, the jury returned conclusions of unlawful killing contributed to by neglect for Sunny, and accidental death contributed to by neglect for Elena.
Lesley Watts, chief executive of Chelsea and Westminster Hospital NHS Foundation Trust, said: “We apologise unreservedly for the failings in care provided to Elena and Sunny, and our thoughts and condolences remain with their families and loved ones.
“We took immediate action to put measures in place to prevent such tragic incidents from happening again.”
The unit’s neonatal nurse coordinator told the inquest that she had not followed the policy of checking vials thoroughly by picking them up and looking at them at eye level.
She accepted that if she had done so, she would have been able to identify that the vials contained sodium nitrite.
The hospital’s chief pharmacist also admitted there had been a “complete and total” failure in self-checking within the pharmacy, which resulted in a box of sodium nitrite being issued instead of sodium bicarbonate.
Internal investigations in the pharmacy failed to identify who had issued the wrong drug.
‘I miss him every day’
Kerstin Propst, mother of Sunny, said: “I am glad that this inquest process has finally enabled us to gain some answers about what happened to our beloved Sunny, although hearing about the multiple failures and missed opportunities that led to his tragic death were very hard to hear.
“Losing Sunny so needlessly completely shattered the whole family, not just me. He will always mean the world to me, and I am so proud of him. I miss him every day.”
Selina Mazumder, mother of Elena, said: “There’s a lot of mixed emotions, it’s taken four long years to get to this point. We believe the conclusions the jury have come to mirror our own feelings and what we’ve known all along. Which is the catalogue of failings were really serious and negligent and that both Elena and Sunny lost their lives because of these failings and that they should be here today.”
The families were represented at the inquest by solicitor Frankie Rhodes, of law firm Leigh Day.
Ms Rhodes said the verdict would give families “some closure” but highlighted a “catalogue of errors and basic failings from the nurses involved in both babies’ care”.
“It is shocking that these premature babies, some of the most vulnerable in society, were put at risk, and both Elena and Sunny needlessly lost their lives due to failures to do simple checks which are a fundamental part of a neonatal nurses’ job,” she said.
