Extracts from evidence given at the Inquiry yesterday about the Morphine overdose incident on 22 Jul 2013 -
Transcript of Part B Evidence: - Anne McGlade – Children’s Ward Manager - Yvonne Farmer – Registered Practice Development Nurse - Yvonne Griffiths – Neonatal Deputy Ward Manager
thirlwall.public-inquiry.uk
Yvonne Griffiths – deputy NNU manager
Q. So I would like to turn, please, to ask you about clinical incidents before the period that we will focus on in due course, the first being the morphine infusion incident on 22 July 2013.
A. I believe Eirian wasn't on duty. I think she was on annual leave. I was informed of the incident and because it was a very serious incident with morphine, I did seek help from my matron as well on how to handle the follow-on from the Datix.
Q. Very serious incident?
A. Yes.
Q. Why do you say it was a very serious incident?
A. It was a morphine error on the pump that was infusing. I can't remember the times fold of morphine.
Q. 10.
A. 10-fold, so if that hadn't been picked up as soon as it was, it might have made the baby demise.
Q. It could have been fatal?
A. Yes. […] It happened -- I think it was handed over at 8 o'clock so the incident occurred at 8 when I was coming on duty.
Q. -- do you mean you were acting as ward manager that day?
A. Correct. […]
Q. I'm not going to name the member of staff, but the other member of staff who was involved, you describe as being terribly upset.
A. She was extremely upset.
Q. And that she came to find you.
A. Yes.
Q. Is that right?
A. Yes.
Q. Are you able to say, for sure, whether Letby did or didn't come to find you on that day to talk about it?
A. No, she definitely didn't. No, the only meeting I had with Lucy was on the one-to-one date of the meeting.
Q. So let's have a look at that now, please. It's INQ0008961, page 47 […] Are you meaning by this that she should not check any intravenous infusions requiring additives and any controlled drugs until the incident review?
A. Correct.
Q. What were you envisaging would occur by way of incident review?
A. I would expect the incident to be, I expected Lucy to be spoken to and, and the pump to be checked. That's what we would normally do for -- to make sure that it wasn't an input error it was a pump error. And I would just expect someone to address it higher than me.
Q. So the incident review, were you expecting that would happen the next day or that it would require a formal meeting, put into people's calendars, what are you expecting by this incident review and when it might take place?
A. Well, I think when I look at the date, 2013, I was pretty new at managing these situations, it was the first incident of a high calibre that I was dealing with, so
I did have advice from my matron. And I just thought it was quite a safe practice to stop her from doing any competent, you know, IVs until it was -- somebody more senior could take that lead.
Q. Then we have
"Complete intravenous competencies, drug calculation, with Practice Development Nurse Yvonne Farmer" as your third action point.
A. (Nods).
Q. Were you expecting, when you wrote this, that that competency drug calculation practice would occur before Letby was signed off to go back to administering?
A. Yes. I think we normally have a process.
So if a medication error is, is made, depending on the severity, then you would do a reflection and then you would have to do competencies before you are able to carry on.
Q. So you were envisaging a circumstance in which Letby met with Farmer, Nurse Farmer, before she was allowed to go back to being involved with controlled drugs in this circumstance?
A. That's what I would have thought would happen.
Q.
Now, what was Letby's demeanour? How was she presenting herself to you in this meeting?
A.
I just remember the comparison because I know the other lady was very distraught and very upset, to the point where she was going to leave nursing. Letby, I think she was upset but not to the same extent.
Q. Now, you have told us that you consulted the matron who was Anne Murphy.
A. Yes.
Q. The most senior nurse on the Children's Unit, is that right?
A. Correct.
Q. Including neonatology. Let's just think about the order of that. Had you spoken to her before you had this meeting with Letby?
A. Yes. I would have spoken to Anne Murphy the day that the incident occurred.
Q. What degree of insight do you think Letby was showing in that meeting, about the severity of the error and the need for remedial steps to be taken?
A. I can't really remember but I think she accepted it and she did actually sign the form, so ...
Q. And if you could go, please, to page 8 and paragraph 39.
A. Yes.
Q. I'll just read it out so you follow along: "In terms of my discussions with Anne Murphy (Matron for Paediatrics and Children's ward) I remember showing her the 'One to One' form and discussing my plans on actions, which she agreed.
The reason for my discussion with Anne Murphy was due to Letby stating that she was unhappy with my decision following our 1:1 meeting. In response, I stated I would take on board her comments and speak to Anne."
A. Yes, I think perhaps she thought I was being a bit harsh.
Q. So just if we just roll it back a little bit.
A. Yes, yes.
Q. The chronology you have given us to that point was that you spoke to Nurse Murphy before.
A. Yes.
Q. You had an agreed plan, you saw Letby, and Letby was happy with what you decided. The account you have given in your Inquiry witness statement is that in fact your conversation with Anne Murphy happens after your one-to-one, and was only prompted by the fact that Letby was, to use your words, "unhappy" with your decision.
A. Yes. I mean, she wasn't happy but after we discussed it, she, she agreed to sign the paper.
Q. So this is a difficult situation for you to manage as you hadn't, you have told us, done such a review before in such a serious incident.
Was it, in your view, appropriate for Letby to be unhappy with the decision that you had made, bearing in mind the severity of her error?
A.
No, and I think it's not that I want to use the word seniority but I think it's, you know, you have to -- she had --
she was only new into her role. I think she had only been on the unit for –
LADY JUSTICE THIRLWALL: I think quite a lot of people in the room didn't hear that because of the noises from outside.
A.
She was relatively new on the neonatal unit and I think -- and I think any constructive criticism needs to be taken on board by, by nurses
Q. Did it give you at the time any cause for concern that her reaction in the face of this error was to question your decision-making which was based on safety grounds?
A.
I suppose she was just protecting her reputation. I think she didn't want to think that she -- she was being judged so harshly and I think because it had been picked up so quickly she didn't think that the error had caused any harm.
Q. And did that incident lead to a change of policy, that the infusions would not be made up at the end of a night shift but would instead be made up at the start of the day shift?
A. Correct.
Q. Now, if we look, please, at the same INQ that I gave a moment ago, but page 45. That's INQ0008961. Just try to understand -- this is
a note predominantly written by Nurse Powell, I am sure you recognise the handwriting.
A. Yes.
Q. We can see that the first action is, and there is a symbol I'm not sure that I am able to interpret it: "
To continue for care for infants ..." "IC", is that including "infusions"?
A. Yes.
Q. Yes.
A. Yes, with, yes.
Q. "
Is able to check CDs" -- is that controlled drugs?
A. Yes.
Q. And then to go over with Yvonne Farmer the pump settings, calculations?
A. Yes.
Q.
So if we just think about what you had decided, supported by the most senior nurse. It was, as you have told us, that she couldn't do either of those first two things until a review had been carried out and that she couldn't do either of those things until she had done the practice with Yvonne Farmer. This is seven days later.
A. (Nods).
Q.
Do you agree that on the face of it, it's something of a countermand to what you had decided should happen?
A.
Yes.
Q.
And we can see that it's not in fact until 6 September that those calculations are recorded as having been done? So was this something that Nurse Powell spoke to you about at the time?
A. No. It's the first time I've seen this one-to-one form.
Q. And I mean, did you have cause to be on the ward and see whether Letby was performing infusions or checking controlled drugs following the incident?
A. I find it difficult to answer that question. I -- I suppose I acted in the best interests in her absence and
Eirian then has gone on and done this other -- I don't know where she made these decisions or what her thought process ...[…]
Q. I would just like to show you one more thing. INQ0012033. That's the new version of that document, page 171, the one that was shown earlier. So this, I hope, is something that you have seen before today?
A. Yes.
Q. And we can see here she's being asked about the drug error, and this is
on 1 August, so this is just after her meeting with Nurse Powell and just over a week after her meeting with you:
[LL]:
"Thankfully Eirian felt it had been escalated more than it needed to be. Everything is back to how it was and I just have to have more training on using the pumps and it will be on my record for six months. She was very supportive. It is a case of learning to live with it now and getting my confidence back. I am on nights this week. Still feeling a bit vulnerable and thinking what if, but I'll get there in time. Thanks for asking." Just to give you an opportunity, Ms Griffiths, to say, just given what you were told on the ward on the 22nd, given the steps that you took, did you escalate it more than it needed to be?
A. No.
