Doctors cleared over baby overdose death

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The Independent Online
TWO DOCTORS accused of covering up a massive morphine overdose given to a premature baby were found not guilty of serious professional misconduct yesterday by the General Medical Council.

Louise Wood was one day old when she received a morphine dose 100 times the intended amount at Rotherham District General Hospital on 1 October 1995. Within an hour of the two injections she was dead.

Dr Vivian Michel, 45, a registrar, administered the fatal dose. Dr Jean Shorland, a consultant paediatrician whose job included monitoring drug dosages, instructed him to complete a "potentially misleading" death certificate, which made no mention of the overdose, the GMC professional conduct committee heard. The consultant should have known the morphine overdose was a possible cause of death, the committee found.

Dr Shorland also should have immediately informed the coroner about the death of the baby.

The consultant admitted to making "a grave error of judgement" in not referring the case to the coroner. She said she believed Louise's death was caused by respiratory problems. Dr Shorland reported the matter to the coroner when she realised there was cause for concern, said her barrister, Robert Seabrook.

Announcing the decision, Sir Herbert Duthie, chair of the GMC professional conduct committee, told both doctors: "Taking all relevant matters into consideration, the committee has adjudged you to be not guilty of serious professional misconduct."

Outside the hearing, Dr Michel said: "This has been a very long and distressing time for everyone involved, especially Louise's family, and I realise that the matter has been fully investigated. I'm very pleased with the decision that the GMC has reached today."

Allegations by nurses that they had warned Dr Michel the dose was excessive were found unproven.

The morphine was supposed to sedate the seven-week premature baby, who weighed 1.5kg and was suffering breathing problems, so that a chest drain tube could be inserted.

The dose was drawn up by Hilary Evans, a junior doctor, who made an error in calculation and placed a decimal point in the wrong place. The dosage should have been checked before being administered but it was not, the GMC was told.

Dr Evans, 29, of Bromsgrove, Worcestershire, was found not guilty of serious professional misconduct on Tuesday.

Louise's grandmother, Dorothy Wood, of Rotherham, said yesterday the family was "disgusted and distressed" by the decision. "It was upsetting when it happened. It brought it all up again now, and we feel it was for nothing."

An inquest in February 1997 recorded an open verdict on Louise's death but criticised Dr Evans for her mathematical skills.

Mrs Wood said: "We feel that it was right that Hilary Evans was let off. She was made a scapegoat."