STV NewsThe families of children who received just a tenth of the morphine they should have been given after cardiac surgery at Scotland’s largest children’s hospital are taking legal action against NHS Greater Glasgow and Clyde.
Seven children, the youngest just 11 weeks old, were underdosed following operations at Glasgow’s Royal Hospital for Children in June 2025.
A review by NHS Greater Glasgow and Clyde found the underdoses were caused by a mix-up in the hospital’s medication ordering system, while overworked and fatigued staff missed a series of safety checks that should have identified the error.
One of those pursuing legal action is Ellie McAdam, whose son Theo was among the children affected.
Theo was two years old when he underwent open-heart surgery at the Royal Hospital for Children in June 2024.
A critical mistake meant he received just a tenth of the morphine he needed – 1.5mg instead of 20mg.
STV NewsHe seemed to be recovering well until he woke up in agony. Ellie recalls Theo was found screaming and covered in blood after he ripped out his IV lines.
She shudders to think of the pain he may have felt during the surgery.
“You put so much trust in these people and so much faith in them, and then they let you down. It’s just catastrophic. You can’t really understand how something so simple could be so wrong.
“Because he’s non-verbal, we don’t know how he feels. We don’t know what going to the hospital makes him feel like. He just has to kind of sit in and do that without being able to communicate how he’s feeling or if he’s scared.”
Theo’s diaphragm is now paralysed on the right-hand side, meaning his right lung cannot fully inflate, leaving him at greater risk of chest infections.
He also has a stent in place between his pulmonary artery and heart to buy him time before requiring further open-heart surgery.
STV News“It’s so frustrating to know that [the incident] was completely unavoidable,” Ellie said. “My child is now left with lifelong injuries and psychologically it’s going to live with him forever. He’s been through enough and he’s only five.
“You’re riddled with this horrible feeling that there’s more to come. We want to reassure him but we can’t. We don’t know that it will be fine.
“When your child needs life-saving treatment, you should put them in knowing there’s risks to the treatment – not risks because of incompetence, negligence, or assumptions.”
STV News first spoke to Ellie in March, when the underdosing incident first came to light. A subsequent review found a medication ordering error and failures in the checking process contributed to the mistakes.
She says she hadn’t heard from the NHS for several weeks after she made her initial complaint.
“We’d been fighting every moment since then, just to be heard, and they didn’t really seem to want anything to do with it.
STV News“Their report was just 16 pages of excuses. Apologies don’t matter if you’re not going to change your actions to avoid repeating the same things again.
“You’re changing people’s lives and you just continue on with your day because that’s your job, but it’s our lives. You can’t just sweep that under the carpet, write on paper, and move on from it.
“This isn’t a witch hunt. I’m not after anybody’s job. I know the NHS is under a lot of strain but you’re holding children’s lives in your hands and making basic errors.”
Theo, along with many of the other children involved will need to undergo more surgeries throughout their lives.
Jonathan Howat, from Thompsons Solicitors Scotland, says the families want evidence of change, as well as answers and accountability.
“They placed their trust in the health board, and that trust has been lost,” he said.
“We’re not talking about one isolated error. It’s a catalogue from start to finish. It raises the question: how was it allowed to go on without being identified much earlier?
“We want to know exactly what changed, and evidence of those changes being implemented.
“The families don’t want other families to go through what they went through.”
A spokesperson for NHS Greater Glasgow and Clyde said: “We would like to once again offer our sincere and unreserved apologies to the patients and families who were affected by this error and for the distress this caused.
“The Significant Adverse Event Review involved the views and questions put forward by the families affected, and the final report, which was shared with families, looked to address these concerns. We would encourage anyone with outstanding concerns to contact us.
“Significant improvements have been made to ensure incidents of this nature are prevented from happening again, and work is ongoing to complete the actions set out in our Significant Adverse Event Review report.”
Follow STV News on WhatsApp
Scan the QR code on your mobile device for all the latest news from around the country
