The doctor who prescribed a dose 10 times higher than intended to a dying two-month old baby has apologised to the family for not informing them of her error.
Hanna Faheem, of Brightside, who was born in October 2012 with an incurable chromosome condition known as Edward’s Syndrome, was taken to Sheffield Children’s Hospital by ambulance on December 16 with a chest infection.
She died in the early hours of the next morning after receiving a dose of morphine 10 times higher than intended – though her cause of death was given as a chest infection and Edward’s Syndrome, not the dosage.
Consultant Dr Ruth O’Reilly told an inquest at Sheffield’s Medico-Legal Centre into Hanna’s death she prescribed 3.5mg of morphine instead of 0.35mg when a nurse asked her to help the baby’s comfort.
She described the moment she made the mistake when working out dosage for Hanna’s weight.
Dr O’Reilly said: “I was writing it up. I said 0.1mg per kilogram. Then I said 3.5mg and I wrote 3.5mg.”
She said she would have expected the dosage to be checked by nurses, saying ‘my experience is that that would usually happen.’
But she added: “I am fully taking responsibility for the error in calculation.”
It wasn’t until she realised the error 90 minutes later that she went to check on Hanna – but said she did not notice any ill effects.
Asked why she did not tell the family, she said: “Can I first of all apologise to the family.
“I am sorry for any distress my actions have caused. I didn’t want to upset them any further.
“Clearly that was an error of judgement on my part and that wasn’t my decision to make.”
Later, she did not tell another doctor to contact the coroner, adding: “It’s not that I was trying to hide anything, but in my mind I felt that Hanna’s death was an expected death and inevitable.
“This was an error of judgement. I was very tired and I clearly should have referred the case to the coroner in the same way I should have told Hanna’s parents.”
The inquest continues.