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Premature baby 'killed by nurse errors and equipment shortages'
Anna Davis, Health Reporter30.10.09
A prematurebaby died after blunders by nurses and equipment shortages at Great Ormond Street Hospital, an inquest heard today.
Nurses looking after Poppy Davies admitted she died of a glucose overdose after a machine that was supposed to prevent this happening was given to another child.
The five-week-old died at Great Ormond Street on 1 February. The inquest at St Pancras coroner's court heard alternative equipment to keep her alive was wrongly set up.
Poppy, born at 24 weeks, was one of the most vulnerable patients in the hospital. She was suffering heart failure, fluid on her lungs and septicaemia.
Nurse Rebecca Tite, who was undertaking an intensive care course at the hospital, was assigned to care for her and on 11 January changed the glucose machine. She said she would have preferred not to have had to do so. Mrs Tite also had to change Poppy's concentration of glucose solution because it was being administered through a vein in her arm rather than a central line into her body.
The court heard that a series of errors in setting up the equipment were not spotted and an alarm indicating there was a problem was ignored six times.
A "three-way tap" that should have made sure Poppy was not given too much glucose was switched the wrong way and a clamp on the tube was left open. Claire Kirk, senior staff nurse at Great Ormond Street, said: "During the morning a nurse came round and asked if there were any IVACS [pumps] because they were getting an emergency admission. I looked round the whole unit to see whether there were any spare."
She gave Poppy's machine to the other child, who was bigger and needed more fluid. After the switch Poppy became more ill and had to be hand-ventilated. Then the glucose machine's alarm sounded, the court heard.
Ms Kirk said: "I remember the alarm going off but I was ventilating her and I didn't have time to look at it."
Her parents David Daly, 21, and Carly Davies, 22, were at the inquest. Mr Daly, a fireplace fitter, said: "I know what happened. I don't need all of this [the inquest] to tell me. I don't know why a nurse with just three weeks experience was looking after Poppy.
"I knew the three-way tap wasn't working properly but I didn't realise there was a second safety check that wasn't carried out."
The Metropolitan Police investigated Poppy's death but made no arrests.
The inquest continues.
