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Two premature twins 'would have survived' if they hadn't been given 10 times too much morphine, inquest told
16:13 GMT, 3 May 2012
Maggie Oldham from Mid Staffordshire NHS Foundation Trust. The trust has set up an inquiry after premature twins were given 10 times the prescribed dose of morphine
Two premature twins given 10 times the prescribed amount of morphine at a scandal hit hospital would have probably survived an inquest has been told.
The drug was given to Alfie and Harry McQuillan after they had been born 13 weeks early.
An expert in premature babies said on the balance of probabilities the tiny babies would have survived but they had been ‘knocked off course’ by the overdose.
Their health deteriorated and they died, hours apart, two days later suffering from lung injuries, bleeding around the brain and other health problems.
Despite being born prematurely at Stafford Hospital, the identical twins had been in a ‘good’ condition during the first few hours of their lives, an inquest into their deaths at Stafford heard yesterday.
It was decided to give the twins morphine to stabilise them before they were transferred to the maternity unit at the University Hospital of North Staffordshire, where staff and facilities were better equipped to look after premature babies.
But confusion and uncertainty between staff at Stafford Hospital over the dilution of the drug meant the babies were given too much morphine and oxygen levels in the twins’ blood began to drop.
Alfie was given 600mg of morphine and Harry 850mg, against a prescribed amount of 50mg.
A quantity of Naloxone, used to combat morphine overdoses, was made up, but was not administered as the twins were stable on a ventilator.
The inquest heard that it was probable the twins’ health had been “knocked off course” by the accidental overdose before they died.
However, Professor David Field, professor of neo-natal medicine at Leicester University, said it could not be directly linked to their deaths, due to the prematurity of their births and associated health risks.
Stafford Hospital, where Alfie and Harry McQuillan died
He said: 'It seems as clear as one can be from the notes that the babies were quite stable, and then there is evidence of instability in both twins.
'Their heart rates slowed and there were problems with monitoring the level of oxygen in the blood.
'The chances are the babies would have survived if they had not been knocked off course by the morphine, but I can’t be sure of that beyond all reasonable doubt.'
The twins’ mother, Ami Dean, from Stafford, was rushed to Stafford Hospital in the early hours of October, 30 2010 after she began to bleed.
She gave birth to Alfie at 5.09am and Harry one minute later, and they were both on morphine by 7.10am.
The inquest heard the maternity unit at Stafford had a “very low” level of staff on the ward at the time.
Professor Field said: 'Staff were inexperienced and didn’t quite understand the dilutive procedure.'
The twins were transferred to the UHNS where they died on November 1.
The cause of deaths was given as a complication of extreme prematurity.
They died 20 months after a report showed appalling standards of care at Stafford Hospital put patients at risk and led to some dying.
Doctor Roger Malcolmson, who carried out the post-mortem, said: 'From the past history of extremely premature babies, death is likely to have been by natural causes, with an increased risk because they were twins.'
Police investigated the deaths but decided there was no criminal case.
Coroner Andrew Haigh will record his verdict on May 23.