Ebbw Vale mum forgives nurse whose error led to new-born baby’s death

FATAL ERROR: Baby Maisie Waters, pictured recovering from an operation, died because her feeding machine was wrongly programmed

HUMAN ERROR: Maisie Waters died at Bristol Royal Hospital for Children

TRAGIC: A nurse’s blunder killed baby Maisie Waters

First published in News South Wales Argus: Photograph of the Author by , Reporter

A GRIEVING woman yesterday said she forgives a nurse whose mistake led to her new-born baby dying after being fed a day’s worth of food in just one hour.

An inquest into the death of seven-dayold Maisie Faith Waters finished in Bristol on Tuesday, with her heartbroken mother Laura Bennett, 23, saying she bears no grudge towards nurse Martyn Woods.

She said: “He came up to us and apologised (after the inquest), which took a lot of courage. At first I was bitter, but now I know his account, I know he didn’t do it intentionally, he just made a mistake, a big mistake.

“We’ll never bring Maisie back and while it’s 10 times worse for us, he’s got to live with it for the rest of his life.”

The inquest at Flax Bourton heard Maisie died while being treated at Bristol Royal Hospital for Children after being born with a congenital heart defect on August 16 last year.

Ms Bennett, from Willowtown, Ebbw Vale, said she prayed for Maisie every day after an atrioventricular septal defect, which meant the walls of heart were missing, was picked up on the 20- week scan.

She and partner Ryan Waters, 24, did not prepare a room for Maisie, as they worried about her survival chances.

However, a planned Caesarian-section at St Michael’s Hospital, Bristol, went well, with Maisie born a relatively healthy 5lb 6oz and able to breathe unaided, before being placed on a ventilator.

She was transferred to the city’s children’s hospital as she waited for open heart surgery in Birmingham.

Doctors told the couple Maisie had a 75 per cent chance of getting through that operation, with Ms Bennett saying: “I kept looking at her thinking ‘Is she really mine?’ “I was so happy, Maisie was in an incubator, but was fine.

“They said there were no guarantees she would have got through the operation, but she was strong and I think she would have. All I wanted was to give her a chance.”

On August 22, the parents left Maisie's side to allow nurses room to feed her and after they returned, they realised something was wrong, when they saw doctors starting to rush around.

Ms Bennett added: “We were taken to a quiet room and didn’t know what was going on.

“A doctor then came in and said they had been doing CPR for 45 minutes and there was nothing more they could do.

“I was numb, it was like I wasn’t there and looking in on someone else’s life.

“They asked if we wanted to be there when she passed away, but I couldn’t watch her die.”

The couple were allowed to hold Maisie and say goodbye.

They were given a memory box by nurses, which included a lock of her hair and then arranged a packed funeral back home at Ebbw Vale.

Now, over a year later, Ms Bennett is still coming to terms with it, saying: “I see other people pushing prams and think it should be me.

“We were robbed of a daughter, granddaughter and great-granddaughter.

“Hopefully they’ve learnt lessons and nobody else will have to go through this.

But, it shouldn’t have taken my daughter dying for measures to be brought in.”

Ms Bennett said the inquest gave her the answers she needed, but she would talk to her solicitor before considering taking any civil action.

A spokeswoman for the University Hospitals Bristol NHS Foundation Trust said: “On behalf of the Trust, I’m deeply sorry for the human error that led to the tragic death of Miasie Waters and our thoughts are with her family at this very difficult time.

Immediately following Maisie's death, the Trust conducted an indepth investigation to ensure human error like this cannot reoccur.

All actions arising from these investigations have been completed or are ongoing.”

Coroner told mistake led to a fatal dose

THE inquest heard Maisie died after her intravenous feeding machine was wrongly programmed to dispense 24-hours feed in 60 minutes.

It required a nurse to programme how much of a formula called Total Parental Nutrition (TPN) should be given to Maisie on an hourly and daily basis.

But when nurse Martyn Woods re-configured the machine, he mistakenly entered the daily dose of 210ml under the hourly rate, the inquest was told.

As a result, she was given 28 times the 7.5ml she should have received in one hour.

Mr Woods said he believed the mistake happened after the machine beeped at him, which he thought indicated he needed to re-enter the 24-hour dosage.

Maisie went into cardiac arrest with doctors unable to revive her.

Coroner Maria Voisin returned a narrative verdict which said: “Maisie was a patient in the Paediatric Intensive Care Unit.

She was born with a heart condition which meant she required surgery.

“On August 22 she died when she was erroneously over infused with TPN.”

She added that the hospital had carried out an immediate review of her death and changes have now been made to procedures.

Comments (4)

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3:27pm Thu 15 Nov 12

On the inside says...

We all make mistakes and it doesn't really matter. For people like nurses the consequences are potentially horrific. I hope most of us would accept there was no harmful intent. However, for the mother of this young child things can never be that easy to understand. For her to accept the nurses apology is a clear demonstration that she is a very remarkable young woman.
We all make mistakes and it doesn't really matter. For people like nurses the consequences are potentially horrific. I hope most of us would accept there was no harmful intent. However, for the mother of this young child things can never be that easy to understand. For her to accept the nurses apology is a clear demonstration that she is a very remarkable young woman. On the inside
  • Score: 0

3:52pm Thu 15 Nov 12

Bobevans says...

This seems to be down to a lack of proper process and procedures at the hospital and possibly improvements to the equipment.

The first problem was the nurse programmed the machine in error but appears not to have checked it was programmed correctly. With something critical like this there should always be a proper check in fact there should be a log book recording who programed it and it being signed it had been checked as being correct. There should also be a second independent check.

The software of the machine could possibly be updated to prevent an overdose, This could be done by requiring data such as the age and the weight of the child to be entered this would then limit it to the maximum safe dose
This seems to be down to a lack of proper process and procedures at the hospital and possibly improvements to the equipment. The first problem was the nurse programmed the machine in error but appears not to have checked it was programmed correctly. With something critical like this there should always be a proper check in fact there should be a log book recording who programed it and it being signed it had been checked as being correct. There should also be a second independent check. The software of the machine could possibly be updated to prevent an overdose, This could be done by requiring data such as the age and the weight of the child to be entered this would then limit it to the maximum safe dose Bobevans
  • Score: 0

12:21pm Fri 16 Nov 12

Dee-Gee says...

Terribly, terribly sad story and how enormously courageous of Ms Bennett to grieve without a grudge. What an inspirational woman.
Terribly, terribly sad story and how enormously courageous of Ms Bennett to grieve without a grudge. What an inspirational woman. Dee-Gee
  • Score: 0

9:49pm Fri 16 Nov 12

SASHA.P says...

My heart goes out to this mum and im really genuinly sorry to hear of her loss but I completly understand her forgiving the nurse as if I was in her shoes I would do the same ,things can happen by accident or human error and its only from these mistakes that proper procedures can be out in place to prevent it happening again but what a terrible thing to go through.But on another note It certainly makes a change to hear of somebody not sueing the NHS and taking much needed funds from other childrens treatments people forget the fact the NHS have a budget and when people keep sueing them for this that and the other its the patients that get hit the worst I would hate to think I could be taking money that could pay for equipment to save another childs life I think some people can be very selfish with no consideration to how their actions affect others as for me im just greatfull we have a an nhs to help us as there never used to be one and with the way things are going there may not be one in the future its hard enough to get an appointment at the doctors let alone get help from the hospital
My heart goes out to this mum and im really genuinly sorry to hear of her loss but I completly understand her forgiving the nurse as if I was in her shoes I would do the same ,things can happen by accident or human error and its only from these mistakes that proper procedures can be out in place to prevent it happening again but what a terrible thing to go through.But on another note It certainly makes a change to hear of somebody not sueing the NHS and taking much needed funds from other childrens treatments people forget the fact the NHS have a budget and when people keep sueing them for this that and the other its the patients that get hit the worst I would hate to think I could be taking money that could pay for equipment to save another childs life I think some people can be very selfish with no consideration to how their actions affect others as for me im just greatfull we have a an nhs to help us as there never used to be one and with the way things are going there may not be one in the future its hard enough to get an appointment at the doctors let alone get help from the hospital SASHA.P
  • Score: 0

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