Nurses were unprepared to deal with twins, inquest told

An inquest heard how nurses at Stafford Hospital were unprepared for an emergency admittance which led to the deaths of twin baby boys.

Alfie and Harry McQuillan were given an overdose of morphine on October 30, 2010 after their mother Ami was admitted for a Caesarian just 27 weeks into her pregnancy.

The boys were given 600mg and 850mg of the drug respectively against the prescribed 50mg dosage by a nurse who had never administered morphine to babies before.

Professor David Field, an independent witness brought in as an expert in neonatal medicine, from Leicester University, said the hospital was not best suited to deal which such an emergency but had ambulance staff taken the mother to the better equipped hospital in Stoke-on-Trent she may have bled to death.

It meant the babies were delivered at 5am when staffing levels were low and although nurses initially coped well, they were doing many different jobs.

"And in that process, an error occured," said Professor Field.

Staff nurse Joanne Thompson insisted the levels were correct after referring to notes she had made in her diary.

Nurse Lisa Lucas, who made the infusion, administered the morphine at 6.50am to Harry and 7.10am to Alfie, but she noticed they were showing signs of deterioration at around 7.30am.

She told the inquest that both she and staff nurse Thompson had failed to spot the correct dosage in the drug protocol guide. "I cannot forgive myself for not checking harder," she said.

The twins were transferred to the Stoke hospital but died on November 1.

The inquest heard Harry suffered a haemorrhage which had nothing to do with the overdose. A post mortem ruled they died from complications caused by their immaturity.

Professor Field said: "The hospital was faced with two unstable twins in a setting where expertise was strictly limited." Mid Staffordshire NHS Foundation Trust said it could not comment at this stage.