An inquest has heard that a premature baby died after being given a ‘massive overdose’ of glucose when a nurse training at the hospital failed to check equipment.

The Daily Mail reports that Poppy Davies from Basildon in Essex was born at just 24 weeks’ gestation on Christmas Eve 2008, weighing less than a bag of sugar. She was rushed to London’s Great Ormond Street Hospital for Children, where she was cared for in the premature baby unit.

Poppy was recovering from routine surgery in January and was connected to a glucose machine to help boost her energy. However, a nurse caring for her – named as Rebecca Tite – was still training and had only spent three weeks at the hospital’s neonatal unit.

The inquest into Poppy’s death heard that Mrs Tite failed to set up the equipment correctly and as a result the glucose being administered flowed freely into the baby’s system without being monitored for more than an hour.

Mrs Tite had failed to check the safety clamp on the syringe drive that provided glucose. She told the court:

‘I didn't check the roller clamp because I would always normally put the roller clamp down when I was preparing fluids.’

The inquest was told that other nurses failed to respond to alarms on the baby’s equipment because she was being ‘treated for breathing difficulties’. Dr Reid said that the errors contributed to a ‘domino effect’ in care that led to the baby’s death.

Doctors attempted to save Poppy’s life by giving her insulin, but the glucose levels had reached more than twenty times the maximum level they should have been and the baby died on 1 February.

Police investigating her death said there were no suspicious circumstances and the coroner Dr Andrew Reid returned a narrative verdict, saying the circumstances of Poppy’s death were a ‘tragic accident’.

Dr Reid told the inquest:

‘I have come to the conclusion that this was a tragic accident in the course of her healthcare. It reflects a number of features recognised in terms of clinical risk management, where there are a number of steps that have not been taken to prevent the outcome occurring.’

He added that it was not possible to know whether Poppy would have survived had the overdose not been given – doctors told the inquest the baby had been in a fairly stable condition, but had suffered from septicaemia and heart and kidney problems before the overdose.

Mrs Tite – who told the inquest she had more than six years of caring for ‘very sick’ children before her placement at Great Ormond Street – has since left the hospital of her own volition, saying she had found the incident ‘devastating’.

Poppy’s mother Karly Davies was too upset to comment after the inquest, but her father David Daly said that he hoped the hospital ‘had learned from its mistakes’.

'It's heartbreaking, but what can you do? You've just got to carry on fighting,’ said Mr Daly.

© 5r1 Limited 2009