A premature baby was HIV-tested after nurses at Lewisham hospital twice made potentially serious errors involving giving it breast milk from another mother.
In the first blunder, Zene Yates, then just two weeks old, and being kept in an incubator, was fed milk through a tube which had come from the mother of another baby in the neo-natal unit at Lewisham Hospital.
Although the hospital apologised and tested the mother for HIV and Hepatitis – which proved to be negative – staff compounded the error when they gave Zene’s parents breast milk from yet another mother to take away from the hospital.
Zene’s parents, Phil and Sarah Yates, from Hither Green in Lewisham, then decided she should be given an HIV test by their family doctor, although they did not know whether they had actually fed any of the second milk to their daughter. The test was negative.
Although doctors say the possibility of passing on such diseases are extremely limited, Mr and Mrs Yates said the implications of the incidents had horrified them. Expectant mothers are offered testing for HIV and other serious conditions in the first few months, but it is not mandatory and infections can be picked up during pregnancy.
Mrs Yates, 25, said: “We were devastated at the possible implications for our baby when we thought about what diseases could have been passed on. This was something that could have been nothing, but it could also easily have turned into a nightmare.”
The couple said they had now decided not to pursue any legal action for compensation but had decided to speak out instead to draw attention to what they believe are sloppy procedures.
The couple stressed that despite the errors, they were still deeply grateful to staff in the neo-natal unit for the care given Zene, now seven months old, who was born weighing just over 3lbs in May after Mrs Yates unexpectedly went into labour eight weeks early.
Zene had been in the unit for two weeks before Mrs Yates was told by a consultant that a bottle of another mother’s breast milk had been connected to the tube. The nurses had fed Zene 20mls of the milk before realising their error, but managed to extract 10mls of the milk back.
The second error was not discovered until several weeks after their daughter was released when Mrs Yates was defrosting some stored in their freezer. The bottle was clearly labelled with another mother’s name but nurses had failed to see this.
Mr Yates, 28, a web developer. said: “Zene was in the neonatal ward for two and a half weeks and twice unnecessarily exposed to potential disease through someone else’s breast milk. It is clear to us there are insufficient checks in place to see that the right milk is being given to the right babies and or parents.
“Something clearly has to change. We do not want for someone in the future to be informed that their child has a disease or infection that could so easily be avoided.
“We’d feel horrendous for not speaking out about our experience and making people aware that the procedures are flawed and need revising.”
Mrs Yates said she felt incident had lessened the bond between her and Zene because the breast milk she had been expressing on a daily basis – which was labeled and stored by nurses – was the only thing connecting them, since the baby was isolated in the incubator.
“It was distressing to think that an unknown woman’s milk had been and was inside of her. I found it difficult to re-bond with Zene because I felt that being fed someone else’s breast milk had weakened the mother-daughter bond, I felt she was a little less mine and then felt awful for feeling that way. Happily, the bond with Zene is strong once again,” she said.
The incident is another blow to the reputation of the hospital which was last year rated the worst in London and one of the worst dozen in the country by The Dr Foster Hospital Guide, a story which ELL covered here.
The guide said it was the worst in the UK for giving suspected stroke victims prompt CT scans, that the mortality rate for heart attacks among patients was nearly 10 per cent above the national average, and the death rate for those admitted with broken hips was ‘’unusually’’ high.
In other reports over the last two years it was ranked third worst in the country for responding to safety alerts designed to prevent fatal errors re-occurring and its accident and emergency department was deemed one of the ten dirtiest in the country.
Only last week the hospital was forced to pay undisclosed damages to an Essex man left paralysed from the neck down after the hospital failed to diagnose a spinal abscess in time.
The hospital said the nurse involved has been disciplined for not, as was required, checking with a colleague that the right breast milk was being used. It said although the other mother was HIV negative at the beginning of her pregnancy and was not ‘at high risk’ of becoming HIV-positive, further tests had been conducted. In the second incident, the hospital said the ward matron had inadvertently taken a wrong bottle from the freezer used to store milk.
In its letter the hospital admitted it was “truly sorry” for the mistakes and that its procedures governing expressed breast milk “not as robust was we thought they were.” A working party had been set up to examine the issue and staff reminded of their responsibilities. A hospital spokesman said today: ”We have apologised to Mr and Mrs Yates and made improvements to how we store and manage breast milk in the Neonatal Intensive Care Unit to reduce the risk of this happening again.”
Although HIV positive mothers were once told not to breast feed, advice in the UK has recently changed to allowing breastfeeding so long as they are receiving treatment. The risk of infection from just one bottle is considered small.
Other potentially fatal diseases, such as Hepatitis A and B and tuberculosis can be transmitted if the mother is not receiving treatment; in cases of TB, the baby should also be immunised. Chicken pox can be passed on if the mother is contagious. Ironically, normal colds and flu are not usually transmitted.
Until the risks posed by HIV/Aids became well known in the 1980’s, all excess breast milk was usually stored communally in ‘milk banks.’ Donated breast milk is still stored in this way, but screened in advance and its use subjected to guidelines laid down by NICE.
No national guidelines exist for normal maternity and neo natal units such as Lewisham, with individual maternity units required to set their own standards.
Sue Jacobs a breast feeding expert at the Royal College of Midwives said: “You can’t safeguard for every eventuality but in larger institutions it becomes more unmanageable. Policies and procedures should definitely by re-examined in order to stop something like this, which I see as very serious, from happening again”.
By Emily Bridewell