Coroner finds neglect by hospital staff contributed to death of ten year old boy

14.08.14 | |

A Coroner has found that neglect by staff at Queen Elizabeth Hospital in Woolwich contributed to Thomas Warren's death. The Coroner found that Tom Warren, a 10 year old boy , physically disabled by cereal palsy, died from an over dose of fentanyl, an opiate painkiller more than 50 times stronger than morphine. The drug was unlicensed for use in children like Tom who were not taking opiates already and was prescribed at the maximum dose permissible for those who are. Pharmacy staff queried the original prescription which was for twice the maximum daily dose for a child used to opiates but went on to dispense the drug when the doctor agreed a reduction in the dose. Tom's parents were not informed the drug was unlicensed nor given any information as to signs of overdose.


The inquest has concluded more than 5 years after Tom's death owing to complexities of the medical evidence. Determining the cause of death was complicated by the finding of myocarditis and human parvovirus DNA in his heart, as well as toxicity results showing potentially fatal levels of Fentanyl. The coroner heard evidence from a leading virologist, a consultant anaesthetist specialising in pain management,  consultants in paediatrics and emergency medicine and 3 pathologists  before concluding that Fentanyl was the cause of death. In addition he found the failure of the prescribing doctor to admit Tom to hospital to monitor his reaction to the drug and failures in the provision of pharmacy services, including the failure to follow dispensing guidelines and to provide Tom's parents with adequate information, all contributed to Tom's death.


Sarah Elliott QC representing the family was instructed by Powell and Co.


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