Inquest identifies that infusion pump inadvertently set to administer TPN over 60 minutes rather than 24 hours


Intravenous news: South Wales Argus report “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.”

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