A report in the Sunday newspapers told the tragic story of the death of Jake Stanley, a three year old who suffered a fatal cardiac arrest after being given seven times as much medication than he should have been following admission to Whiston Hospital on Merseyside after two seizures.

A nurse had prepared the medication in a syringe, but not labelled it.

A doctor then picked it up, believing it to be the correct dose despite not having checked with the nurse and injected Jake with it.

This was at 6.30 pm and Jake was tragically declared dead at 7.15 pm. One can only imagine his parents’ disbelief and horror.

The Senior Coroner, Christopher Summer, concluded there was

“a gross failure to provide basic medical attention to Jake and that his death was brought about by neglect”.

He went on to say that there was a

“total breakdown in communication….”. The nurse admitted to not following protocol in having another nurse check the contents of the syringe and most alarmingly of all, the Coroner commented “….an omission made, it would appear, not for the first time”.

The Trust concluded protocols had not been followed.

It cannot be denied that the NHS is in trouble. It lacks finances, staff, resources and is generally buckling under the need for the service it struggles to provide. There are many reasons for this, but this dreadful incident was not as a result of any of them. It was sheer carelessness, lack of thought and common-sense and a failure at the most basic level of communication, none of which costs money to remedy.

As Claimant lawyers, we are seeing more and more of what we call “systems failures”. This is literally where the systems and protocols put in place to safeguard patients are not followed, or not followed correctly and as such lead to avoidable disasters. Possibly sometimes it is due to a shortage of staff to fulfil the chains of command, but what does it cost to just take a minute to ask someone if you’re not sure? We find there has often been a failure to take control or responsibility and make decisions using clinical judgment, which doctors and nurses are trained to do. There can be too much emphasis on “waiting for test results”, “There was no-one in x-ray so I couldn’t do anything”, “I switched the CTG off as it didn’t seem to be working properly” “ I couldn’t get hold of the consultant on duty” and meanwhile, patients are deteriorating before staff’s eyes.

This is not finance, it’s management and responsibility. No amount of money thrown into the NHS would have prevented Jake’s death. One simple question “Is this injection ok to give?” would have done.

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