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Tuesday, March 9, 1999 Published at 09:24 GMT


Health

Doctor's 'tiredness' killed baby

Benjamin Adams was given ten times the normal dose

A doctor has blamed tiredness for mistakenly administering a fatal dose of a heart-slowing drug to a new born baby.


The BBC's Daniel Boettcher talks to Carl and Tina Adams
The parents say the tragedy has caused them two years of "torture and grief", but doctors' leaders say such mistakes are inevitable because NHS staff are under such unrelenting pressure.

An inquest heard that Dr Christiaan Slabbert told police he missed out a decimal point when writing the prescription for baby Benjamin Adams.


Andrew Hobart of the BMA Junior Doctors Cttee: 1 in 6 doctors still works outside the agreed limits
At the time, Dr Slabbert was more than 14 hours into a 24-hour shift.

Baby Benjamin died after receiving ten times the recommended dose of the cardiac drug Digoxin.

Apology

The South African doctor apologised to parents Carl and Tina Adams when he appeared at the inquest in Kidderminster, Worcestershire, into the baby's death.

Dr Slabbert, who now works in Arkansas, USA, refused to answer questions on the advice of his barrister.

But when asked by the Adams' family solicitor, Paul Balen, if he wished to say anything to the parents, he said simply: "I'm sorry."

Tina Adams, 25, who now has a nine-month-old son, broke down as the medic left the witness box at Kidderminster Town Hall.

Benjamin was just a few hours old when he was given ten times the recommended dose of Digoxin at Redditch's Alexandra hospital in April 1997.

Respiratory problems


[ image: Carl Adams says the family has suffered
Carl Adams says the family has suffered "torture and grief"
The blunder occurred after the baby developed respiratory problems and a fast heart beat shortly after his birth by Caeserean section on April 25.

Doctors at the hospital's paediatric department sought advice from cardiologists at Birmingham Children's Hospital, who recommended the use of the drugs Adenosine and Digoxin.

Adenosine was to be prescribed at a rate of 100 mcg per kilo of the baby's weight and Digoxin at 10 mcg per kilo, the inquest heard.

The dosage was written on the patient notes by the senior physician, Dr Neel Kamal, and left to Dr Bridget Wilson and Dr Slabbert to write up the prescription, the hearing was told.

The adenosine was administered by Dr Wilson and began to improve the baby's condition.

The digoxin was then administered by nursing staff working from the prescription written by Dr Slabbert.

Police statement

In a statement to police at the time of the incident, Dr Slabbert, 38, said he had been tired when he made the mistake, and was on his second 24-hour shift during the week of the death.

The statement, read in court by Worcestershire Coroner Victor Round, read: "I had had a demanding day. I was on duty for a 24-hour period.

There was a degree of tension due to the bed and staff shortage."

The doctor, who told police he had "no real experience" of prescribing intravenous cardiac drugs, was called to several births, received referrals from GPs and attended to patients in casualty during his shift, before being required to write the prescription.

He told police: "I then made the calculation but inadvertantly failed to retain the decimal point.

"I was quite tired, having been on duty since 9am the previous morning and working continually without much of a break, I had not even been able to have an evening meal."

Dr Slabbert's failure to include the decimal point led to the 7lbs 1oz baby receiving 320 mcg of Digoxin instead of the recommended dose of 32 mcg.

The Alexandra Healthcare Trust has admittted liability and the family, of Fir Trees Close, Batchley, Redditch, have received 7,500 compensation, the maximum pay-out for the death of a child.

Family grief


[ image: Tina Adams says the pain will not go away]
Tina Adams says the pain will not go away
Carl Adams said his family had suffered suffered two years of "torture, sleepless nights and untold grief".

He said: "I don't believe these people know what their incompetence has done to our lives, I really don't."

Tina Adams said the family were still suffering.

"It does not go away, it stays with you every day."

Mr Andrew Hobart, chairman of the British Medical Association's Junior Doctors Committee, said doctors were working extremely long hours in the NHS.

"This is an inevitable consequence of the fact that the UK has fewer doctors per head of population than almost any other civilised country in the world," he said.

"When doctors in training are working long shifts it is vital for patient safety that the doctors have adequate rest periods."



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