Jury concludes Sunny Parker-Propst was unlawfully killed and neglect contributed to the of death Elena Ali

The inquest heard how Elena and Sunny  were both given Sodium Nitrite instead of Sodium Bicarbonate while under the care of Chelsea and Westminster Hospital NHS Foundation Trust.

Elena was born prematurely on 16 April 2020. Her condition was deemed moderate, so she was stabilised on the delivery suite. Two days later, her blood gas was taken during routine monitoring which showed she had too much acid in her blood (metabolic acidosis), for which she was prescribed a Sodium Bicarbonate infusion. However, the inquest will hear that she was mistakenly given a Sodium Nitrite infusion and died that day.

 
Elena Ali.                                                       Sunny Parker-Propst.

The neonatal nurse coordinator gave evidence at the inquest where she accepted that she knew of the policy to check vials thoroughly by picking them up and looking at them at eye level, but she did not follow the policy. She accepted these are fundamental steps to take and that if she had taken the vial in her hand and looked at eye level, she would have been able to see Sodium Nitrite.

Evidence was also heard from the hospital’s chief pharmacist, who the coroner said had admitted there had been a “complete and total” failure in self-checking within the pharmacy, which resulted in a box of Sodium Nitrite being issued instead of Sodium Bicarbonate. Internal investigations in the pharmacy failed to identify who had issued the wrong drug.

Both families still do not know how a drug, that would never be needed in the neo natal intensive care unit, was checked out of the pharmacy and delivered to and stocked in the NICU cupboard under the heading Sodium Bicarbonate.

Sunny was born prematurely two weeks later on 30 April 2020, and he was transferred to the NICU for continuing care and prescribed a Sodium Bicarbonate infusion due to metabolic acidosis. Sodium Nitrite was administered in error after it was wrongly stocked on NICU and selected by nursing staff, checked by two staff and given by two nurses not noticing it was potentially the wrong drug. Sunny died on 9 May 2020, just weeks after Elena died under the same circumstances.

It was heard how, had proper practice been applied, nurses would have noticed they were administering nitrite. Vials should have been checked properly and procedures should have been followed with timings recorded correctly and multiple nurses overseeing the process, with checks being restarted if anything was not done properly. When the potential drug error was recognised, the clinical staff should have been informed straight away. It was highlighted how the checks were basic and safety should come first, irrespective of the pressure the nurses were facing and if done properly, they would have realised it was nitrite and the deaths would not have occurred.

Selina Mazumder, mother of Elena, said:

“There’s a lot of mixed emotions, it’s taken four long years to get to this point. We believe the conclusions the jury have come to today mirror our own feelings and what we’ve known all along. Which is the catalogue of failings were really serious and negligent and that both Elena and Sunny lost their lives because of these failings and that they should be here today.

“We hope the lessons learnt can be shared with all NHS trusts and that the CQC and the MHRA reassess these cases following this verdict and enforce change.”

Kerstin Propst, mother of Sunny, said:

“I am glad that this inquest process has finally enabled us to gain some answers about what happened to our beloved Sunny, although hearing about the multiple failures and missed opportunities that led to his tragic death were very hard to hear.

“Losing Sunny so needlessly completely shattered the whole family, not just me. He will always mean the world to me, and I am so proud of him. I miss him every day.”

The families are represented by Suzanne White, head of Leigh Day’s clinical negligence department, and Leigh Day solicitor Frankie Rhodes.

Frankie Rhodes said:

“I am pleased that after much hard work and four long years, which involved an investigation from the CQC, the Metropolitan Police and now the conclusion of the inquest, the families can hopefully have some closure. However, it is still unclear exactly how the medication made its way onto the NICU from the pharmacy, having been returned by the A&E department.

“In addition, there was a catalogue of errors and basic failings from the nurses involved in both babies’ care. It is shocking that these premature babies, some of the most vulnerable in society, were put at risk, and both Elena and Sunny needlessly lost their lives due to failures to do simple checks which are a fundamental part of a neonatal nurses’ job.

"It is also disappointing that there were delays in the inquest process due to late disclosure of documents, including important medical records, which were required in evidence and for witnesses refer to during the inquest.

"It has been a privilege to represent these families and support them through this very difficult process.”

Suzanne White said:

“The tragic loss of two babies' lives could have been entirely avoided by the most basic checks by the medical professionals involved in their care. Inexplicably Sodium Nitrite, a dangerous drug, which should only be kept on the accident and emergency department was not identified on the NICU until after Elena and Sunny were poisoned and sadly died.

"The neonatal nurses failed to do the most basic and fundamental drug checks to make sure that both premature babies were begin administered drugs safely.

"The lack of basic care and attention to detail in this case is utterly shocking but also tragic and devastating for the families and their babies who will live with these consequences for the rest of their lives.”