Seven children were given a tenth of the pain relief they should’ve been after undergoing open-heart surgery last summer at Scotland’s largest children’s hospital, STV News can reveal.
NHS Greater Glasgow and Clyde (NHSGGC) has apologised to the families of the children who were given ten times less morphine than they should have been at the Royal Hospital for Children in Glasgow.
The under-doses affected seven individual operations over six days within a single theatre between June 13 and 24 last year. A Significant Adverse Event Review (SAER) into the cause is now under way.
Last month, STV News spoke to Ellie McAdam, mum to three-year-old Theo McAdam who is one of the children impacted by the wrong dosage.
Two more families have now told STV News that the mistake has shaken their trust in the standard of care provided at the hospital.
‘Shocked and devastated’
STV NewsTwo-year-old Kai Campbell was born with a congenital heart defect – he was scheduled for surgery at the Royal Hospital for Children on June 19, 2024.
His parents, Jordan Campbell and Shelby Wilson, were told Kai would be sedated for two days after the procedure.
Once the youngster was taken into recovery, they were told to go home and rest.
Just hours later, Shelby and Jordan were called and asked to return to the hospital as Kai had woken up, distressed.
‘It feels like they didn’t know what they were doing.’
Jordan Campbell, Kai’s dad
“When we went into intensive care, he was awake,” Shelby told STV News.
“He was up and down, upset and crying. He wasn’t staying sedated, and he didn’t seem comfortable at all. We just thought this was normal after this surgery. It was his first time, so it was all new to us.”
Jordan added: “He was in distress, trying to pull out tubes, and they were giving him more medication to try to sedate him. He’d fall asleep for five or ten minutes and wake up again. They just kept saying he’s a wee fighter.”
Jordan CampbellKai was discharged a few days later, and his parents say he had “bounced back” to his usual self.
Eight weeks later, Jordan received a call from his son’s medical team stating that there had been a mistake.
The morphine dosage Kai had been given while in recovery was ten times lower than he should have received – 1mg instead of 10mg.
“I was shocked and devastated – thinking, ‘Kai was lying there, not being able to tell you if he’s okay,'” Jordan recalled.
STV News“He can’t tell you, ‘Dad, I’m in pain.’ That’s the hard thing. To me, it feels like they didn’t know what they were doing.”
Kai will need more surgeries in the future – but Jordan and Shelby say they’re “terrified” of what could happen.
“That was his first surgery so we’re really scared to do it again,” Shelby said.
STV News‘There was blood everywhere’
Another woman whose son was also given too small a dose of morphine following open-heart surgery told STV News she feels let down by the hospital and the health board.
Choosing to remain anonymous, she said her son had just turned three when doctors discovered a “hole the size of a 50p coin” in his heart.
A surgery was scheduled at the Royal Hospital for Children on June 20 – the day after Kai.
“They closed the hole in his heart with no issues,” the mother told STV News. “We were allowed in to see him at 4.30pm; he had been sedated, so we were told to go and check into our hotel while they woke him up.
‘We’re grateful he’s fine – but very angry that this happened by people that we trusted.’
Anonymous mother
“My husband and I were back at the hospital within the hour, and as we were walking to the PICU, we could hear him shouting for us. He’d pulled out his cannula and his feeding tubes – he was still sleepy but not sedated.”
Aside from seeming agitated, though, his behaviour didn’t ring any alarm bells for his parents and medical team.
“He had a really unsettled night that night. The doctors didn’t know why as he’d had all the pain relief he should’ve had,” she told STV News.
“When we went to see him the next morning, his drains were still in – but there was blood everywhere – so we did assume he’d tried to pull them out.”
STV NewsDespite this, the three-year-old’s parents were told since he was older, he was recovering quicker – they took him home on June 23, three days after the operation.
He seemed to be doing well at home, behaving as he normally would – but just over a month later, on July 30, his mum received a phone call stating there had been a mistake.
The child, like Kai, had been given ten times less morphine than he should’ve been for pain relief after the open heart surgery.
“We’re grateful he’s fine – but very angry that this happened by people that we trusted to care for him,” his mum told STV News.
“I feel very let down – there’s no trust left. I hope that surgery is is done and dusted with them, I don’t trust them with his care anymore.
“They need to review their practices and protocols. How was this missed despite the various people that doses have to go through?”
‘No answers’
Three-year-old Theo McAdam ripped all his lines out in pain when he was given ten times less morphine than he should’ve been on June 24 – collapsing his own lung.
Theo now has a paralysed diaphragm due to the incident.
Reacting to the news of two more families speaking out, Ellie told STV News: “To find out there are a number of other people affected is really harrowing. We’re all in the same boat, and we’re confused as to how it went unnoticed for so long?”
Ellie McAdam“When the investigation is finally done, I hope we will all get the answers we are looking for because right now, we have none.“
Ellie says she’s asked NHSGGC for an update on the SAER regarding the incident and was told statements from various departments are still being formulated.
Due to the lifelong nature of all three boys’ conditions, she says their parents have “no choice” but to put their trust in the medical team again – and while she feels gratitude to the team for carrying out the operation successfully, she’s “terrified” of the aftercare.
STV NewsStock ordering system issue
Dr Claire Harrow, deputy medical director for acute services at NHSGGC, told STV News an issue with the hospital’s stock ordering system had led to the incorrect doses of morphine being administered.
She apologised to the impacted families and stressed the hospital’s “robust” protocols, which usually prevent mistakes.
Dr Harrow said: “I understand the shaken trust, and I am sorry that this has happened, and I’m sorry for those individual families.
“The Significant Adverse Event Review is at a near completion, and it will be with the families within the next few weeks.”
STV NewsShe added: “When the issue was identified, checks were put in place and we conducted a Rapid Review of all our stock orders and our processes around that.
“Further recommendations may come out of the Significant Adverse Event Review, in which case we will, of course, take them very seriously and make sure that they are put into place.”
Dr Harrow said she understood fears members of the public may have about bringing their children to the hospital and offered reassurances that steps were being taken to ensure a high standard of care.
“I would seek to reassure anyone coming to either the children’s hospital or to Greater Glasgow and Clyde sites that we’re an organisation that takes patient care very, very seriously,” she said.
“It’s our first priority – we have dedicated staff working very, very hard to care for people who are often in their times of greatest need.
“We have robust safety checks and balances in place, we listen to feedback, we look for trends of incidents, and we investigate and act accordingly.”
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