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Thursday, April 22, 1999 Published at 14:45 GMT 15:45 UK


Consultant doubted overdose killed baby

The senior doctor involved in the case gave evidence

The consultant in charge when a premature baby was given 100 times too much morphine has said she did not think the overdose had caused the baby's death.

The BBC's Sophie Dekker: "Dr Shorland says she did not try to mislead the baby's parents"
Dr Jean Shorland also denies she tried to cover up the circumstances of the baby's death.

She and Dr Vivian Michel face charges of serious professional misconduct at the General Medical Council.

The charges relate to the treatment of one-day-old Louise Wood at Rotherham District General hospital in October 1995.

Louise died after she was given the overdose.

However, the morphine incident was not mentioned on the baby's death certificate.

Respiratory problems

Dr Michel told the hearing on Wednesday that Dr Shorland was not present when the overdose was administered.

On Thursday, Dr Shorland told the GMC's professional conduct committee that when she arrived on the scene she spoke to Dr Michel.

"I listened to the sequence of events as told to me by Dr Michel and I thought that the features of her illness were of respiratory problems," she said.

"I had experience of a morphine overdose just two months before in a similar situation. A baby was given 10 times too much but the mistake was spotted almost immediately and nothing happened to the baby.

"So I did not think 100 times morphine equalled death. I thought we had counteracted the morphine and the problem was respiratory."

She said this was why she did not mention morphine on the death certificate, which she instructed Dr Michel to fill out.

She also denied that she tried to mislead Louise's parents about the overdose, but admitted she had made an error of judgement by not reporting the death to the coroner immediately.

It was only after reporting the death to the coroner on 3 October that she realised that Dr Michel had injected the overdose.

Until that point she had thought Dr Hilary Evans had done it. Dr Evans was cleared of serious professional misconduct charges on Tuesday.

Dr Evans was in fact responsible for preparing the dose.

'Mistakes happen all the time'

Earlier on Thursday, Dr John Puntis, a consultant at the neo-natal intensive care unit at Leeds General Infirmary, told the hearing that mistakes in drug dosages happen all the time in hospitals.

He said Dr Michel should have been able to trust Dr Evans, a junior doctor, to draw up the correct dose.

"This mistake could have happened in my unit at any time. It's the type of problem that could happen in any neo-natal care unit," he said.

"A lot of problems happen in intensive care units."

Junior doctors are expected to have a reasonable standard of mathematical skills and to be aware of the need to dilute certain drugs, he said.

But he admitted that in retrospect it would have been preferable for Dr Michel to have double-checked the dose, but that this omission was understandable in an emergency.

On Wednesday Dr Michel wept as he gave evidence to the hearing and apologised to the baby's parents.

The hearing continues.

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