Eleven-month-old girl was the second patient to receive fatal overdose of anti-seizure drug phenytoin at Surrey hospital within six months, inquest hears

  • Eleven-month-old Sophie Burgess was rushed by ambulance to Surrey hospital
  • She had a seizure in June 2016, but died after being given the drug phenytoin
  • Caroline Pearson-Smith also died that year after being prescribed the same drug

A baby girl was the second patient to receive a fatal overdose of the same drug at a Surrey hospital within six months, an inquest has heard.

Eleven-month-old Sophie Burgess was rushed by ambulance to St Peter’s Hospital in Chertsey after suffering a seizure on June 16 2016, but died after being given the drug phenytoin.

An inquest in Woking was told on Friday that another patient at the hospital died after receiving a ‘significant’ overdose of the same anti-seizure drug in January 2016.

Caroline Pearson-Smith died on January 25 2016 at the hospital after being prescribed ten time the recommended dosage of the same drug. 

Dr Paul Murray, the NHS hospital trust’s chief of patient safety, told Surrey Coroner’s Court it was only after Sophie’s death that a ‘substantial response’ was triggered in regard to the dangers of the drug.

He said that, while phenytoin is effective, it is ‘very complicated’ and can be dangerous.

Eleven-month-old Sophie Burgess died after being given the drug phenytoin in hospital 

The inquest heard that Dr Lojein Hatahet and paediatric consultant Dr Fiona MacCarthy had attempted to administer the drug to Sophie using an automated syringe-driver.

It failed to work and it was decided that Dr Hatahet would administer it from a hand-held syringe, despite protests from nurse Polly Leavold, who said the drug was not needed and giving it by hand was against the hospital’s protocol.

Dr MacCarthy said in evidence that she had prescribed 200 milligrams of the drug for Sophie and that she trusted nurses to ensure the dose used was correct.

But the inquest heard that Sophie may have received five times the prescribed dosage – up to 1,000 milligrams.

Dr Fiona MacCarthy attempted to inject baby Sophie with the drug at the Surrey hospital

Dr MacCarthy said she was unaware the phenytoin was not diluted.

Assistant coroner Dr Karen Henderson said there had been a death at the hospital in January that year involving an adult woman who received a ‘significant overdose’ of the drug. 

Dr Murray said in his evidence that the hospital investigated the first death as a prescribing error.

Asked if staff should have been told to be cautious when using the drug following the January incident, he said ‘I wish we had done.’

Caroline Pearson-Smith who died in 2016 after being prescribed ten times the normal dose

Dr Murray said the trust now only uses the drug in its diluted form and that ‘major work streams continue to involve medication safety work’.

There have been four deaths involving the drug nationally, he added.

The inquest was halted in 2017 after Surrey Police asked the coroner to suspend proceedings to allow officers to re-examine the investigation after new evidence emerged during the hearings.

However the force decided not to proceed with a criminal investigation and the inquest resumed this week. 

Dr MacCarthy was not part of Surrey Police’s investigation, her legal representative, Andrew Hockton, said.

Paediatric consultant Dr Mohammed Rahman, who was asked to provide his expert opinion on the case, said ‘it was more likely than not’ that the nurses who prepared the syringe got the dosage calculations wrong.

Dr Rahman said the drug should be administered at 1 milligram per kilogram per minute, but added that it would be ‘difficult’ to follow those guidelines when giving it manually.

He said he would expect any paediatrician to know that the risk of ‘cardiovascular collapse’ was ‘very real’ if the drug was given too quickly.

Sophie’s father, Gareth Burgess, who attended the inquest with her mother, Emma, said doctors told him the drug should be given over a 20-minute period and he had timed the process with his iPhone.

He said that, after about 13 minutes, Sophie vomited mucus, then milk and then soiled herself.

Mr Burgess said the drug was fully given in another two minutes before medical staff started taking emergency steps to try to save the baby’s life.

The inquest heard that Dr MacCarthy had amended her records of the incident to show that the drug was administered for 10 minutes longer than she had previously recorded.

Clodagh Bradley QC, representing Sophie’s parents, who are from Chertsey, asked her: ‘Were you trying to cover your tracks because you knew you had given phenytoin too quickly?’

Dr MacCarthy replied ‘That is incorrect’, claiming the initial entry was an estimate which she later amended after speaking with Dr Hatahet.

She said: ‘This was not in any way a cover-up. This was the worst day of my life.’

The drug should be given over a 20-minute period, or 30 minutes as per the hospital trust’s policy, Ms Bradley said.

Sophie had suffered a series of seizures triggered by a reaction to infections during the last two months of her life.

Assistant coroner Dr Henderson indicated that she would not be ready to reach a conclusion by the end of Friday.

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