A leading medical lawyer has revealed he has serious concerns about the procedures for prescribing and administering drugs at Leeds General Infirmary after a premature baby was given an overdose 10 times the correct level on 10 separate occasions.
Kyle Thistlewaite was born prematurely, at 25 weeks, on 20 April 2007 at Leeds General Infirmary after his mother was transferred from Bassetlaw Hospital in Worksop. On 10 separate occasions in 48 hours he was given a steroid to help his blood pressure that was 10 times the recommended dosage.
Kyle died three days later and although ultimately this medication error did not lead to his death, HM Coroner David Hinchcliff, at Leeds Coroners Court, highlighted the mistake as he recorded the death as prematurity and a brain haemorrhage.
Tim Annett, a medical law specialist from Irwin Mitchell, is representing the Thistlewaite family, he says that this case raises serious concerns about the systems at the hospital.
Annett said: "The family were obviously shocked to learn of the steroid dosage error. This mistake raises important questions about the systems at the hospital for calculating and checking drug dosage. A serious error was made and this was repeated by a number of different staff before it was identified by chance. Kyle's parents want to make sure that this can never happen again.
"Patient safety should be the number one concern of the NHS and it is vital that improvements are identified and implemented to stop what is essentially a very basic error, it is important that the hospital learns from its mistakes."
Craig Thistlewaite, Kyle's father, said: "We were horrified to learn of the dosage error given to Kyle but we are relieved to find out that this did not contribute to his death.
"However it is only right that the coroner highlighted the error. How a baby can be given an overdose so high in the first place is bad but to be given the overdose 10 times is totally unacceptable. I am also amazed that we were not told about the mistake until after our son died and we welcome any further action to stop mistakes like this happening again as we wouldn’t want anyone to suffer the pain we have."
On 21 April 2007 just 24 hours after Kyle Thistlewaite was born he was given a hydrocortisone steroid drug to try and support his low blood pressure. The dosage of the drug was calculated incorrectly and Kyle was given a dose 10 times higher than he should have been. The wrong dose was given a total of 10 times in 48 hours before the error was spotted by chance.
On 23 April 2007 Kyle's condition deteriorated and a decision was made to withdraw life-sustaining treatment after speaking to his parents. Kyle died on 23 April 2007. A post-mortem examination found that Kyle had suffered an extensive intraventricular haemorrhage (Grade IV)*.