Jury concludes Sunny Parker-Propst was unlawfully killed and neglect contributed to the death Elena Ali

A jury has returned conclusions of unlawful killing, contributed to by neglect, and accidental death, contributed to by neglect, in respect of two premature babies poisoned with sodium nitrite in error 12 days apart at Chelsea and Westminster Hospital in 2020.

The ten-day inquest reached a conclusion of accidental death contributed to by neglect for Elena Ali and unlawful killing contributed to by neglect for Sunny Parker-Propst.

The inquest heard how Elena and Sunny were both given sodium nitrite instead of sodium bicarbonate while under the care of Chelsea and Westminster Hospital NHS Foundation Trust.  

The neonatal nurse coordinator gave evidence at the inquest where she accepted that she knew of the policy to check vials thoroughly by picking them up and looking at them at eye level, but she did not follow the policy. She accepted these are fundamental steps to take and that if she had taken the vial in her hand and looked at eye level, she would have been able to see sodium nitrite.  

Evidence was also heard from the hospital’s chief pharmacist, who the coroner said had admitted there had been a “complete and total” failure in self-checking within the pharmacy, which resulted in a box of sodium nitrite being issued instead of sodium bicarbonate. Internal investigations in the pharmacy failed to identify who had issued the wrong drug.  

Both families still do not know how a drug, that would never be needed in the neo natal intensive care unit, was checked out of the pharmacy and delivered to and stocked in the NICU cupboard under the heading sodium bicarbonate. 

It was heard how, had proper practice been applied, nurses would have noticed they were administering nitrite. Vials should have been checked properly and procedures should have been followed with timings recorded correctly and multiple nurses overseeing the process, with checks being restarted if anything was not done properly. When the potential drug error was recognised, the clinical staff should have been informed straight away. It was highlighted how the checks were basic and safety should come first, irrespective of the pressure the nurses were facing and if done properly, they would have realised it was nitrite and the deaths would not have occurred.

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Source: Leigh Day, 22 July 2024