'We put our baby in their hands - she ended up in unnecessary pain'

The parents of a baby who was given a fraction of the morphine she should have after undergoing open-heart surgery say they are still seeking accountability.

Baby Charlotte Gilchrist is one of seven children who were given a tenth of the pain relief they should have been after undergoing the surgery last summer.

The underdoses affected seven operations over six days within a single theatre between June 13 and 24 last year but were not discovered until nearly a month later, on July 6.

A review by NHS Greater Glasgow and Clyde (NHSGCC) following the incidents found that overworked and fatigued staff at the Royal Hospital for Children in Glasgow missed vital checks.

Charlotte was just 11 weeks old when she under went open-heart surgery.

‘You can see she was in pain’

Charlotte’s mum Coral told STV News: “I kept saying there is something not right (with Charlotte) – I didn’t want to be right.”

“You automatically think the worst”, Charlotte’s father, Craig, said.

Everything froze for the couple until after a two-hour-long surgery when they were supposed to be in the clear.

The family still thinks of the videos they took of Charlotte post-surgery.

“Now, when we look back at videos, I feel dead guilty because, you can see, she’s in pain”, Coral explained.

The couple later discovered that Charlotte was given an underdose of crucial morphine following the procedure.

A review found the seven children, including Charlotte, were administered 1mg/ml of morphine – when they should’ve received 10mg/ml.

The report also found that the underdose went unnoticed for nearly a month due to staff going on “assumption” rather than doing two-person checks as procedure requires.

NHSGCC has apologised to the families and said it has begun implementing the recommendations in the report.

But Craig and Coral say that they are still “heartbroken” and don’t think the recommendations are enough.

Coral told STV News: “We handed over our world to somebody else’s arms and they didn’t look after her the way they should have.”

‘The report findings are not enough’

The Significant Adverse Event Review (SAER) by NHSGGC also found staff were overworked and overtired during shifts.

The review recommendations included additional staff training and an improved stock management system to ensure “any incident of this nature is prevented from happening again”.

But families affected say that isn’t enough.

Coral added: “There were lots of minor issues that were just careless, and there were a lot of them.

“It was bad enough she had to go through heart surgery, and even though we’re thankful, she was still in unnecessary pain.

“We deserve to find out what has actually happened with that. Are there disciplinary hearings going ahead?

“You can give all the training you want, but unless it’s implemented in practice, it’s not going to make a difference.

“Over a year after her surgery, and we’re still having to relive that with every email and every conversation.

“When you properly sit and think about it, it breaks your heart”.

STV News spoke to two other families affected by the incident, who are also disappointed and feel like the review raises more questions than it answers.

Ellie McAdam, mum to three-year-old Theo, said she felt the report was a “half-hearted acknowledgement of not following policy, but it falls short of real accountability”.

Two-year-old Kai Campbell’s mother, Shelby, shared the sentiments, adding that she was “shocked” as the report “was just full of so many excuses.”

While Charlotte won’t need any more heart surgery, Coral still wants to ensure no parent or child goes through the same ordeal.

Carol said: “My heart goes out to the families who have gone through this and do need future surgeries.

“I know how anxious it’s made me, and I can’t imagine how anxious they are knowing that some point in the future they will need more surgery.”

NHSGCC apologised and said families have been invited to meet with members of the review team to discuss their concerns.

“We know the care these patients received fell below the standard expected, and we are sorry,” a spokesperson for the health board said.

“Both human and systems factors played a role in this incident, and we are committed to ensuring that lessons are learned from this extensive review, which was carried out with the involvement of pharmacy, nursing, and medical staff, as well as an individual panel member providing expert opinion.”

The health board said it began implementing the report’s five recommendations as soon as the error was identified.

“It includes recommendations around staff training, the physical environment and stock management system, which are designed to ensure any incident of this nature is prevented from happening again,” the board said.