A coroner has deemed the death of a five year old girl, who suffered brain damage when just six weeks old after being given prescription baby food containing 124 times the permitted level of magnesium, as a medical accident.
Following a two-day inquest in Galway the parents of Elaine Barrett, from Cloonacauneen, Claregalway, said that they were distressed at having to wait seven years to finally learn what caused their daughter’s death.
Frank and Eileen Barrett criticised the manufacturers of the baby food, B Braun Medical Ltd, of 3 Naas Road Industrial Park in Dublin, and the Irish Medicines Board, whom they claimed knew from their own investigations what had happened to their daughter’s brain a week after the food had been administered to her in May 2003, but had never contacted them to explain their findings in the intervening seven years.
In a statement read out after the inquest Mrs Eileen Barrett said: ”Since this whole ordeal began all we have ever wanted to know is how and why it happened. We will never get justice for our daughter Elaine, but this inquest gives us the answers we have been trying to get for the last seven years.
“We hope that no other family will ever have to experience what we have gone through.”
The couple added that while they accepted the personal apology of Paul Mullaly, managing director of B Braun Medical Ltd. was sincere, they felt it was “too little too late.”
It is understood the couple have reached a settlement with B Braun Ltd. in recent weeks which has yet to be finalised by the High Court.
The inquest heard evidence that an incident had occurred at the B Braun’s manufacturing plant on May 23, 2003 which had caused a computer to temporarily “time out” or freeze as the system was manufacturing a bag of food intended for an adult.
That bag of food was subsequently discarded but, human error and a changeover in staff that morning had caused a standard practice, by which the pipe which still contained some of the adult feed, which in turn contained an adult dose of magnesium, had not been “primed” or flushed out with water prior to the next bag of food intended for baby Elaine, being manufactured.
Her batch of food, IMB senior inspector Mr John Lynch told the inquest today, contained 124 times the permitted dose of magnesium for a premature baby, along with 80 times the permitted dose of zinc.
Mr Lynch said B Braun Ltd. no longer manufacture paediatric TPN bags but have been allowed to continue manufacturing adult feeds.
Baby Elaine was born prematurely at just 26 weeks in Holles Street Hospital on April 16, 2003.
As she got stronger she was transferred back to Galway on May 9, 2003, but required at times to be fed intravenously and was given a product called Total Parental Nutrition (TPN).
This was manufactured by B Braun Medical. Two bags of TPN had been ordered but when the first of these was fed to Elaine on Sunday May 25th 2003, she became extremely agitated and her condition deteriorated.
Doctors in Galway told the couple the following day that high levels of magnesium had been found in Elaine’s blood, having come from the TPN bag supplied by B Braun Ltd.
A subsequent brain scan showed Elaine had suffered massive brain tissue damage and she died five years later on October 16, 2008.