Overdose not cause of baby’s death, coroner finds

A coroner has found there were “significant failures” in the hospital care of a newborn baby girl – but said they did not cause her death.

Polly Lindop, who was born 10 weeks prematurely, died within 24 hours of being born at Manchester’s St Mary’s Hospital on 13 March 2023.

She was already gravely ill with a serious infection when nurses mistakenly gave her 10 times the correct dose of a muscle relaxant.

A spokesperson for Manchester University NHS Foundation Trust said it was committed to improving services and would be “studying the coroner’s findings and conclusion carefully to see if there are further steps which we should progress”.

They said the service has already done its own reviews and taken action after Polly’s death.

Manchester coroner Zak Golombeck said the overdose was a “serious failure” by hospital staff but he found “on the balance of evidence” it had not led to Polly’s death.

A medical expert in the case had told Manchester Coroners Court that Polly’s condition had already been deteriorating and there had been a “very low” chance of her surviving, even without the overdose.

Polly suffered a cardiac arrest six minutes after being given the drug Atracuriam, and died within a few hours.

However, a post-mortem examination found the primary cause of death was sepsis and prematurity, and that she had suffered severe lung damage.

The inquest had been told nurses on the neo-natal intensive care unit were using unfamiliar equipment when they administered the drug to Polly.

One of the nurses involved in her care accepted there were missed opportunities to check the dose.

The court was told medical staff at St Mary’s Hospital had also failed to give Polly’s mother Kimberly Lindop a second antibiotic before Polly’s birth – which the coroner also described as a “significant failure” but not contributory to Polly’s death.

Before delivering his conclusion, the coroner strongly denied claims by Polly Lindop’s father that the inquest process had been biased in favour of the hospital.

Mr Golombeck rejected accusations that he had failed to properly investigate claims, made by Polly’s family, that the hospital had tried to cover up the mistakes made by medical staff.

The inquest was told there was no mention of the overdose when hospital consultant Dr Gareth Penman initially reported Polly’s death to the coroner.

Dr Penman later apologised to the Lindop family, saying he never intended to cover up the failure.

The coroner said Dr Penman should consider whether to refer himself to the medical regulator the General Medical Council over the matter.

Following Polly’s death, Greater Manchester Police started an investigation into possible gross negligence manslaughter.

But the force later said no criminal charges were being brought.

The Manchester University NHS Foundation Trust spokesperson said: “We offer our deepest condolences and apologies to the family of Polly Lindop.”