A South London coroner has written to NHS England chief Amanda Pritchard urging her to share on a country-wide basis the learnings from the tragic death in 2020 of an infant due to a combination of factors including a morphine dosage error partly caused by limitations in the PMR formulary.  

When Juanita Boate Nti was born in May 2020, she was diagnosed with Townes-Brocks syndrome with tracheal stenosis and complex congenital heart disease, with doctors determining that her condition was untreatable.

From July 1 that year, she received palliative care and “was tenderly cared for by her parents at home” with a symptom management plan including morphine solution administered via a naso-gastric tube as required, wrote London Inner South senior coroner Andrew Harris in his prevention of future deaths report, which was made public this week following an inquiry that was first opened in March 2021.

While the hospital prescribed 120mcg to be given every six hours, the strength and volume “were not clearly recorded on the plan sent to the GP,” said the coroner. Sending the prescription to the pharmacy, the GP selected the only available strength of morphine on the EMIS prescription system – 10mg/5mls – and then “confusingly” added the further instruction: “100 micrograms per ml solution, 120 micrograms 6hrly.” 

This second line was missed by the pharmacist, who “dispensed the higher dose without stipulating the volume to be administered,” meaning the baby “received 3mg instead of the intended 150 micrograms.”

On September 3 2020 her condition deteriorated following a morphine dose and she was taken to hospital, where she died in a paediatric intensive care unit. The cause of death was cited as a combination of her underlying condition and an accidental overdose. 

Noting that the prescription was written “just before a bank holiday during the pandemic” at a time when GPs and pharmacists were under considerable workload pressures, Mr Harris said: “Whilst both GP and pharmacist made errors in clinical practice and did not contact each other, the error would not have occurred had another strength of morphine been a choice on EMIS.

“EMIS have been notified and placed the special prescription on its drug database. The local commissioning group is conducting a project to identify other special prescriptions that are not on EMIS that may pose a similar risk to safety.”

He concluded: “Juanita was very fragile with limited life expectancy, but would not have died when she did, without the overdose, naturally having less reserve to recover from the intoxication.”

Mr Harris advised Ms Pritchard of the local response from hospitals, GPs and pharmacists following the incident, which has led to revised repeat prescription policies and a revised paediatric formulary, but said a similar incident that took place subsequently in the North of England highlighted the need to apply these learnings “across the whole of the NHS”.

Ms Pritchard is required to respond to the coroner’s report by Friday October 13. NHSE declined to comment when approached by P3pharmacy.