Leading children's hospital fined £75,000 for premature baby death caused by 'human error'

A premature baby died from a massive drugs overdose because of 'human error' at a world-famous London hospital, a court heard.

Guy's and St Thomas' Hospital Trust has today been ordered to pay £75,000 for 'contributing' to the death of Jada Pilkington Asaye.

She suffered haemorrhaging and heart failure after receiving five times the amount of glucose she was actually prescribed.  

A mistake in the hospital's pharmaceutical department led to the tragic mix up, causing the two-day-old baby's death.  

Southwark Crown Court heard Jada and her twin brother, who died at birth, were born at just 25 weeks on April 24 2006, weighing the same as a bag of sugar. 

Her mother Lorraine Pilkington had Jada at Chelsea and Westminster Hospital, in south west London, but the special intravenous feed needed for premature babies had to be ordered from Guy's and St Thomas' Hospital.

A prescription setting out the exact combination of the glucose, protein and water solution was sent to the south London hospital's pharmacy but was not followed.

The machine used to produce the colourless solution was programmed incorrectly, injecting baby Jada with 135milligrams of glucose when she needed just 10mg.
Prosecutor Andrew Bird told the court: 'The pharmacy department manufactured these bags for other hospitals for about £56 each.  

'The bag was made up to order and contained various nutrients required by patients.  
'Doctors in charge of the patient will determine what goes into the patient's bag.' 

Mr Bird continued: 'The machine has to be programmed to deliver set quantities of each of the three compounds which then make up the final solution.' 

Jada's prescription was for just 10milligrams of glucose per kilo of solution, which equalled seven per cent, but she was instead attached to a drip containing 135mg, a dangerous 37.2 per cent.  

The 10mg of glucose was supposed to be added to the solution by syringe but was instead added via the machine.  

Mr Bird said: 'When the bag was prepared at Guy's there was a human error.  
'The bag was supplied and administered to the baby and it gave her a massive overdose of glucose, she died the following day.'  

He told the court a technician at Guy's Hospital had mistakenly added glucose to the solution instead of water and had merely 'turned on the wrong tap'.

The court heard a similar incident had occurred with the machine in 2005 but was spotted before being given to the patient.  

'Those preparing this very specialist prescription would have known that it was being delivered to other medical professionals who, without question, are delivering it to very young patients who would not be able to complain,' Mr Bird said.  

'This particular procedure would have been known to everyone and there is a particular need to get it right.'

At the Jada's inquest last year at Westminster Coroner's Court, a narrative verdict was recorded and one of the causes of death was listed as iatrogenic hyperglycaemia.

Mr Bird said 'iatrogenic' means caused by doctors.' 

Defence counsel for Guy's and St Thomas' NHS Trust, Steven Climi, said the Trust apologised for the mix up but that the glucose overdose was just 'one of the many factors contributing to her death'.  

'The trust would like to make a public expression of sympathy to the family of Jada from all concerned at the Trust, at every level,' he said.  

He went on: 'There have been 100,000 bags like this prepared by the Trust in 15 years. These are just two incidents using this process.

'These are well qualified, well trained pharmacists and technicians operating machinery they are familiar with, that they have used numerous times and that system went wrong because of a human error.'  

Mr Climi added that the technician and supervisor responsible for the blunder, were 'devastated' by the baby's death.

Judge Nicholas Lorraine-Smith imposed a fine of £75,000 on the trust but said he recognised that 'no fine would begin to reflect the value of the child's life.' 

'The trust have prepared 100,000 of these bags over the years, and with just one exception, there has been no failing such as this,' the judge said.  

He added: 'The post mortem listed possible causes of death and iatrogenic hypoglycaemia caused by the contents of the bag was one, but the coroner also found this was one of a number of factors that contributed to the death.

'The Trust have accepted that human error caused this and there has been a public expression of sympathy at every level.

'In 2005 there was a similar incident but it was detected before any damage was caused.

 'I am satisfied that it was investigated thoroughly and various options were considered to remedy the situation but it was decided that the system should remain because altering it could cause more mistakes.' 

Jude Lorraine-Smith concluded: 'I have to sentence the trust for this offence against a background of an excellent reputation but recognise the awful truth that their error was a contributing factor in the tragic death of a young baby. 

'No fine can reflect the value of that child's life and no fine I do impose removed money that goes to the Trust's primary purpose of providing healthcare.' 

The Trust was also ordered to pay £2,916 in costs.  

The NHS Trust has admitted one count of selling a medicinal product not of the nature and quality demanded by purchaser.  The hearing continues.