Five Year Old Boy Died After Overdose Administered By Four Hospital Staff

Bailey’s Mum Says She Is Relieved Hospital Trust Has Learnt Valuable Lessons From Tragic Incident


A devastated mum of a five year old boy who died after doctors and nurses at a West Yorkshire Hospital administered an overdose of medication has spoken of her anger about her son’s death following a damning verdict from a coroner who said his death could have been prevented.

Bailey Ratcliffe, from Lindale Mews, Batley, died on 27 May 2009 after a massive overdose of epilepsy drug phenytoin caused his heart to stop.

An inquest held this week at Bradford Coroner’s Court heard how staff at Dewsbury and District Hospital made catastrophic mistakes calculating the dose of the drug – even though four members of staff were involved in his care.

Dr Peter Straker, the Coroner for Bradford, recorded a narrative verdict and said that an inappropriately high dose of phenytoin was prescribed. He said that unfortunately a number of individuals did not recognise the error and therefore did not intervene and prevent Bailey from dying. He concluded that Bailey died of phenytoin toxicity complicated by his epilepsy and underlying medical conditions.

Bailey’s mum Carrianne instructed specialist medical lawyers at Irwin Mitchell’s Leeds office in her battle for answers and justice against the Mid Yorkshire NHS Trust, which has already admitted liability for his death in a civil claim. The Trust has also put new protocols in place to ensure similar incidents are prevented in future.

Anna Bosley, a medical law specialist at law firm Irwin Mitchell’s Leeds office who represented Carrianne in her civil claim against the trust and supported her through the inquest process, said: “Bailey’s death was a tragedy and should never have happened. His death arose from a catalogue of errors by not one, but four members of staff, who all failed to realise that Bailey was being given far too high a dose of phenytoin medication.

“Carrianne trusted the hospital to look after her son, and she was badly let down, but she is reassured that lessons have been learned and steps taken to ensure that accidental overdoses are avoided in future.

“This case is a stark reminder that one error can have such devastating consequences for patients and their families. Although nothing can make up for the loss of a much loved and treasured son, the conclusion of the inquest process and the reassurances from the hospital trust that lessons have been learnt will enable Carrianne and her family to try to move on.”

The court heard how on the day of his death, Bailey suffered an epileptic fit at home in Batley. Carrianne gave her son his usual medication but when this failed to ease the fit she called an ambulance to take him to Dewsbury and District Hospital.

After arriving at the hospital the paediatric registrar prescribed Bailey with phenytoin, initially as a loading dose – a one-off dose of a drug which is often given at the start of treatment.

She then ordered a maintenance dose. This is where the error occurred and despite four members of staff being involved they miscalculated the dosage.

When the infusion of phenytoin had been running for around two hours, over which time around 2800mg of medication had gone into Bailey’s system, his condition began to deteriorate and his heart stopped. He was unable to be resuscitated.

Following a police investigation, the Crown Prosecution Service, decided not to pursue any criminal charges against the Trust.

Carrianne, 32, said: “Since May 2009, my life has been turned upside down. My family and I have waited for over three years to finally come face to face with those responsible for the medication mistake and to get answers for what has tormented us since that day. Initially we thought that Bailey had died of epilepsy and it was some months before we discovered that an error had been made with the medication.

 “I was told that Bailey was going to be fine and that he would be kept in overnight for observations. It was such a shock when he deteriorated and it was devastating to watch the doctors try to resuscitate him. We are haunted by what happened. Not one, but four, staff were involved in Bailey’s care and I still can’t believe how they got the drug dosage so badly wrong, but I am glad that this has been reflected in the Coroner’s verdict.

“We would like to thank the family and friends who have supported us through this difficult time and thank the family liaison officers from the police. We would also like to thank our legal representatives from Irwin Mitchell.

“Bailey was such a special character who, despite his health problems, loved life. He was a wonderful gift and he was snatched away from us. We will never get over losing Bailey, especially now when we should be looking forward to Christmas together. But I hope the Hospital Trust will ensure this never happens again so other mums don’t lose their children in such horrible and preventable circumstances.”