Premature twins died after being given 10 times too much morphine, nursing tribunal hears
- Alfie and Harry McQuillan were born at 27 weeks in October 2010
- Were in a 'good condition' despite being born so early, inquest heard
- Prescribed morphine to stabilise them but instead given 'excessive dose'
- Died at scandal-hit Stafford Hospital two days later
- Nurse in charge, Joanne Thompson, now facing disciplinary hearing
- Accused of letting less senior member of staff administer wrong dose
Premature twins born at the scandal-hit Stafford Hospital died after receiving ten times the recommended dose of morphine, a disciplinary hearing has been told.
Alfie and Harry McQuillan, who died on November 1 2010, were given an 'excessive' dose of morphine hours after their birth.
The babies, who were born at 27 weeks, received 600 and 850 microgrammes (mcg) of morphine respectively when they should have been given between 50 and 100 mcg, a Nursing and Midwifery Council (NMC) hearing was told.
Joanne Thompson, a senior staff nurse in the special care baby unit of the hospital, is accused of allowing a more junior nurse, Lisa Lucas, prepare and administer the drug to the twins with the help of a junior doctor.
This is against hospital protocol which states this should be carried out by two registered nurses.
Hayley Amos, a neo natal senior staff nurse at the hospital at the time, said she had reported for duty on the 7am shift on October 30 2010 after the overdose had been administered.
Speaking about the reaction of the two nurses after the error had been discovered, she said: 'Joanne went very quiet at this point and was visibly shocked. Lisa was hysterical and kept saying: "Oh my God, what if I have killed these babies?" and she was crying and shaking.
'I did my best to calm and reassure Lisa by saying, ‘look at them Lisa, they are fine, now calm down’. I don’t recall Joanne saying anything. I sent them to the staff room to calm down.'
The two nurses were told to complete Serious Incidents Forms by senior mangers at the Stafford NHS Trust and told not take part in any clinical care of the twins, Ms Amos said.
She continued: 'Lisa and Jo completed their forms in a consulting room. 'I do not know what discussions were had or what went on between them.'
But she added: 'It seems unfair that only Lisa has been held accountable for this drug error.
'Lisa is a very compassionate nurse who normally provides great care to babies on the unit.
'I do not know what went wrong that day. But you cannot say that Lisa is entirely responsible.
'As the senior nurse, Joanne should have ensured that the hospital's procedure was adhered to and that instruction was given to the junior nurse.
'A controlled drug error had taken place and Joanne should take some responsibility.'
Despite being the senior nurse on duty at the time of the deaths, Ms Thompson was back on duty two days later on November 2nd, before an investigation had began while Miss Lucas remained suspended.
Mrs Thompson denies a series of charges including failing to take the clinical lead of nursing care when required in relation to the administration of the morphine to the babies.
The twins' mother, Ami Dean, was rushed to Stafford Hospital in the early hours of October 30th, 2010, after she began to bleed.
Despite being born prematurely, the identical twins had been in a 'good' condition during the first few hours of their lives, an inquest into their deaths in 2012 heard.
But 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 the twins died on November 1st.
The Nursing and Midwifery Council (NMC) heard today how an error in administration led to the babies having two doses of morphine administered at the same time.
Miss Thompson is accused of not following hospital protocol by allowing a junior doctor to be involved in the administration of medication.
Aj Hall, for the NMC, said: 'On the hospital protocols it clearly states that medication administration should be carried out by two registered nurses. It is well known doctors do not get involved in administrating drugs as this is done by nursing staff.
'Mrs Thompson should have ensured that this policy was complied with. The junior doctor had very limited experience and should not have been involved in administering the drugs.
'Mrs Thompson would have been well aware of this.' She added: 'It is vital she take responsibility for this.'
Thompson is also accused of not keeping adequate records by scribbling out her signature on the morphine prescription charts without explanation, the court heard.
Miss Hall added: 'She scribbled out her signature on the chart but never explained why she did this.'
Shoosmiths - the law firm representing the twins’ parents - said last May that South Staffordshire Coroner Andrew Haigh had described the babies’ treatment after birth as 'suboptimal', adding that 'there were failings in the care the twins received'.
A spokesman for the company said the coroner, who recorded a narrative verdict at Cannock Coroner’s Court, said the boys died from complications of extreme prematurity and that morphine was 'likely to have played a role'.
The hearing comes after the Francis inquiry into failings at Stafford Hospital where it is estimated there were between 400 and 1,200 excess deaths between 2005 and 2009.
The hearing continues.