"Our baby daughter's overdose at Alder Hey"

About: Alder Hey Children's Hospital / Paediatric surgery

(as a relative),

Our daughter, Madison was transferred to Alder Hey Childrens Hospital to undergo a BT Shunt operation in 2005. Surgery was successfully carried out on the 23rd February and she was making a good recovery in intensive care. She was transferred to the high dependency unit on the 25th February with the view to being able to come home within a week.

On that evening she was given her 3rd lot of heparin intravenously, that was supposed to be 1,500 units of heparin mixed in 50ml of saline solution. It is our understanding that the staff nurse and charge nurse between them misread the doctor's handwriting in the prescription book; the doctor had written 1,500u instead of units and the nurses mistook this as 15,000. Over the next 24 hours the solution was slowly fed into our daughter until she died at 10.10pm the following evening (26th February) aged 10 weeks and 3 days.

There are supposed to be safeguards in place in the form of blood clot tests for patients on heparin (which is a blood thinning drug used after operations). It is our understanding that these were supposed to be carried out at 7am on the morning of the 26th but the nurse due to take them was late and between her and her charge nurse they neglected to do them until 3.30pm - 17 hours after the drugs first started being administered.

We went through 21 months of police investigations, an inquest, dealings with the CPS, a GMC enquiry and an NMC enquiry which is still ongoing.

No criminal charges were brought against the people involved, however the hospital trust admitted liability. Recommendations were made to try to prevent a similar tragedy occuring again.

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