A FIVE-YEAR-OLD boy died after he was given an “inappropriately high dose” of a drug when he was taken to hospital suffering an epileptic fit, a coroner has ruled.
Bailey Ratcliffe died after he was admitted to Dewsbury District Hospital on May 27 2009, an inquest has heard.
Senior registrar Dr Helen Moore apologised in court for mistakes made when Bailey was given the drug phenytoin on her orders.
Now West Yorkshire Coroner Peter Straker has delivered a narrative verdict in which he said: “Unfortunately, there were a number of individuals who did not recognise this error and, therefore, did not intervene and prevent Bailey from dying.”
The two-day inquest heard how Bailey had been fitting for three hours when he arrived at the hospital on May 27 2009.
He had been given other drugs by his family, paramedics and A&E staff to try and control the fitting but Dr Moore decided it was time to move on to phenytoin.
But the doctor admitted she made a mistake in the dosage instructions when she asked a junior doctor to prescribe the drug.
The court heard how other doctors and nurses were involved in the administration of the phenytoin and one nurse did question the large quantity of the drug she was being asked to prepare with Dr Moore.
But none of the medical staff stopped Bailey receiving a much larger dose than he was he supposed to.
Dr Moore told the court how she thought she got confused in her mind with the procedures for administering a different drug used in cases of severe asthma.
She said: “I just made a mistake.”
The court heard how Bailey was transferred to a paediatric ward in the hospital but, later that afternoon, he began to deteriorate and stopped breathing.
A full resuscitation team was called in but could not save his life.