A CORONER has said hospital ‘neglect’ contributed to the death of a three-year-old boy who was given an overdose of drugs to treat a seizure.

Jake Stanley, of Windle Hall Drive, Windlehurst, was taken to Whiston Hospital at 5pm, on January 21, 2017, after suffering a seizure.

The inquest at St Helens Town Hall heard Jake had a history of suffering seizures after having an infection.

On his way to hospital, Jake had another seizure and was taken to the accident and emergency department.

At around 6pm, Jake stopped fitting and was attached to a ventilator.
As this was taking place, Dr Thomas Whitby was advised to give Jake the drug phenytoin to prevent more seizures, but the dosage was not discussed.

Staff nurse Tony Mulcahy then prepared a syringe of the medication while Dr Whitby was out of the room.

Dr Whitby said he thought he was given a different dosage to the one he received.

Jake was given the medication at seven times the intended rate and seven times the intended dosage.

At around 6.30pm, when the anti-seizure medication was being injected, Jake went into cardiac arrest.

Attempts were made to resuscitate him but he was declared dead at 7.16pm.

Three factors were examined by senior coroner Christopher Sumner to decide if neglect had taken place on the balance of probabilities.

The coroner considered if Jake was in a dependent position and if a gross substantial failure was made, such as providing basic medical attention.

The third consideration was if the failure contributed to Jake’s death.
Mr Sumner said: “I have no doubt whatsoever that all three factors were indeed present and that neglect played a substantial part in the death of Jake.

“Hospital protocols were breached causing the overdose and subsequent death of Jake.”

“There was a total breakdown in communication in the period that Jake received the drug and confusion as to dosage, concentration and means of administering of it amounting to neglect.”

Nurse Mulcahy recalls he remembered being told by Dr Whitby that he was asked to prepare intravenous Phenytoin but not how it should be prepared.

He drew up the medication and put it into an unlabelled syringe.

The nurse said he was going to label it later but this did not take place.

Mr Sumner added: “By his own admission, nurse Mulcahy did not follow protocols and have another nurse check the contents of the syringe, an omission, it would appear, not for the first time.

“At no stage was a prescription signed.”

In an inquest hearing at St Helens Town Hall on Tuesday, July 3, expert consultant Dr Graham Mould stated that the concentration of Phenytoin “caused adverse effects and was likely to be responsible for Jake’s death”.

The cause of death was recorded through a combination of an anti-seizure medication overdose, a fever-like convulsion and a brain malformation.

A spokesman for St Helens and Knowsley Teaching Hospitals NHS Trust said: “The trust offers its sincere condolences to Jake’s family for their tragic loss.

“When Jake arrived at the hospital by ambulance, he was extremely poorly and required intensive support.

“Following his death, an immediate and thorough investigation was carried out The trust concluded that medicine administration protocols in place were not followed by the staff involved and referred the case to the coroner.

“Appropriate employment procedures are still ongoing.”

To read a family tribute to Jake visit https://bit.ly/2JdJy9X.