Baby overdose: 'catastrophic' doctors' error
Updated on 24 June 2010
Exclusive: An inquest into the death of a baby boy who died after experienced NHS doctors accidently prescribed too high a dose of drugs records a verdict of accidental overdose, of which neglect was a contributing factor, as his mother tells Channel 4 News what went wrong was beyond her "capacity of understanding".
Anna Holzscheiter said her seven-and-a-half month old baby Lucas died "because of a whole series of miscommunication, and miscalculation of drugs between the doctors involved".
According to a police report baby Lucas was given between nine and 12 times the correct recommended dose of a toxic drug for a child of his age and weight.
Doctors involved in the case were banned from prescribing drugs immediately after the event, and have only been allowed to safely continue after internal assessments.
An inquest into the death of Lucas concluded today that his death was the result of an accidental overdose, of which neglect was a contributing factor.
The tragedy has raised serious concerns over the assessment of doctors for prescribing drugs across the country.
Channel 4 News has been told there is a "potential gap in the system" - which led to the death of baby Lucas.
Baby Lucas' parents on doctors' 'catastrophic' overdose
"You remember every single detail and you would rather prefer to erase it from your memory.
"We were completely speechless. We were continuously told that he was in a critical condition but that they had everything under control and they were just following protocol, and that he would be taken to an intensive care unit in a different hospital.
"We were just so shocked to hear that. It was basically at a time when Lucas was just dying, or they were trying to reanimate him and get his heart going again, but it was actually at a time when the whole process was irreversible."
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Mum Anna Holzscheiter and Lucas' father, Benjamin Stachursky, have since returned to Germany to have a second child, fearing their new baby would not be safe in NHS care.
Mr Stachursky told Channel 4 News: "The thought of having another baby in London was just not conceivable for us because we wouldn't have been able to just go into hospital and trust - to put the new baby's life in their hands."
Dr John Coakley, medical director of Homerton University Hospital in Hackney, east London, which admitted Lucas last May, has apologised in person for the "catastrophic error".
Three experienced doctors: a consultant paediatrician, a specialist registrar and a senior house officer, attended to Lucas - who suffered from Sturge-Weber syndrome, which is a rare, but treatable, condition.
Sturge-Weber is a neurological disorder that causes regular convulsions in young children and is often accompanied by a birthmark on the face, known as a port-wine stain.
Following Lucas' death, the senior registrar involved was forced to sit two prescribing assessments. The registrar, who was close to becoming a consultant, failed both.
Dr Coakley told courts investigating the case that prescribing errors are "relatively common nationally and internationally" in all healthcare systems, however he said the mistakes leading to Lucas death were "almost inconceivable".
Benjamin Stachursky, Anna Holzscheiter and baby Lucas
Lucas was admitted to Homerton following a fitting episode on the evening of Friday 15 May last year. Ms Holzscheiter said doctors initially thought he might be suffering from a stomach bug or meningitis.
It was only after his condition worsened that they began to administer anti-epileptic drugs to stop his fits, which had become increasingly regular.
After the initial medication failed, Lucas was given Phenytoin - which slows the heart down and reduces the blood pressure. Once administered, the drug's effect cannot be reversed.
Lucas' parents knew he was being given a new drug, but had no idea of how toxic the drug was. "Of course, we had faith in the system," Mr Stachursky said.
However, according to a police report Lucas was given between 9.79 and 12.57 times the recommended dosage for a child his age and weight - in just over 6 hours - than the amount he should have received in 24 hours.
"We were sitting behind a curtain and could hear the doctors at work and at some point we realised that no one was speaking any longer.
"Then after a while the consultant just came to talk to us and told us that there were serious problems with Lucas' heart rate and they were trying their best to stabilise him but that there was a probability that he wouldn't make it.
"That they had just realised that he had been given a massive overdose of Phenytoin...and there isn't a way of counteracting such an overdose," Mr Stachursky said.
Ms Holzscheiter recalls another doctor crying as they entered the room. "I think that was a moment when I realise that this was a very particular situation," she said.
Lucas, who was referred to Great Ormond Street at three months old with Sturge-Weber syndrome, was a "very lively and happy child", Mr Stachursky told Channel 4 News home affairs correspondent Andy Davies.
He said: "If we look at the whole range of the mistakes that were committed I think it is more or less a miracle that this doesn't happen on a daily basis - you just can't believe the amount of errors, the magnitude of errors and breaches of duty that were committed during the 24-hours or little bit more that we stayed at the Homerton."
Ms Holzscheiter, who is on a two-year post-PHD research grant from Germany in a London Health Policy Unit, said "I can comprehend that human errors happen because he or she is overworked. But it is beyond my capacity of understanding what has happened in this case. Particularly the failure of the doctors to admit where the limits were and to admit that they weren't competent enough to deal with the tasks that they were given and to properly consult with someone who could have known in that situation what was the appropriate step to take. I think this for me is the gravest error actually."
All of the doctors involved were subject to internal assessments after being suspended from presribing, they may yet face disciplinary action.
John Coakley, medical director at Homerton Hospital, said: "This was an absolutely tragic event and we have offered our deepest sympathy and condolences to the family right from the very beginning."
Mr Coakley said it was an almost inconceivable error, the magnitude of such "that clearly the coroner has found it amounted to neglect".
Following the coroner's verdict, Dr Coakley said he would "take appropriate action" towards the staff involved.
"The coroner raised the issue of referral to the regulatory authorities and other authorities to do with safety and medical practice and I will reflect on the coroner's verdict and take the appropriate action," he said.
'Cultural problem' in the NHS
The medical staff invovled are absolutely horrified at the death of baby Lucas, he said. "To say they are devastated at what's happened is a significant understatement," Dr Coakley added.
As a result of the tragedy, doctors in paediatrics at Homerton now face regular prescribing assessments, raising questions over the assessment of doctors across the country.
Dr Coakley said there was a "potential gap in the system" - which led to the death of baby Lucas. "If it happened in our hospital, it could happen in others," Dr Coakley said.
He has been in touch with the National Patient Safety Agency, which has also been notified by the police over the incident, and it is understood that the Royal College of Physicians and local deaneries are looking into implementing similar prescribing assessments for doctors on a wider basis.
"I think we've relied on an assumption that doctors, when they come out of medical school, are competent to prescribe. And we have for some years had a system where we test young doctors as they come out of medical school when they arrive at our hospital...we've never actually extended that assessment to doctors who are more senior, even consultants, so there's a potential gap in the system," he said.
Dr Coakley said the failure in "checks and balances" that led to the overdose of Lucas was a "cultural problem" in the NHS.
"I think it is symptomatic of the cultural problem. Everyone makes mistakes, every single doctor in this country, every day somewhere will make a prescribing mistake. We all do it. But there are checks and balances. The pharmacists check the prescriptions, the nurses check the prescriptions, so there's a whole series."
In Lucas' case, he said the questions were asked, but the answers were "over reassuring".
"How can it happen? Well it happens because perhaps the confidence with which the order is issued - there are a whole number of reasons why people accept reassurance," he said.
The checks that should have been made on Lucas' dosage were not completed as they should have been, according to the coroner's ruling, Dr Coakley said.
"So that doses seem to have been prescribed and then not checked, it was not clear to one doctor that another had already prescribed the drug and it was prescribed in the wrong place, so there were a number of errors made by doctors involved in this case and the combination of all of those errors - if any one of those staff had picked up on one of the errors - then this incident would not have happened."
A Department of Health spokesperson said: "We are working with NHS staff to embed a safety culture across the NHS. The majority of care is safe but we recognise that improvements need to be made.
"The General Medical Council is currently working with the Royal Medical Colleges to improve prescribing skills for both junior and senior doctors. This includes working towards standardised prescribing forms and increased testing of prescribing skills through assessments.
"We expect the NHS to be open about mistakes and ensure that lessons are learned to prevent them from being repeated."
