A Barnsley doctors' surgery issued the wrong prescription for a
baby with fatal consequences, a coroner has said.
Four-month-old Abbie Jones died after being given 10 times her
normal dose of the drug Frusemide.
An inquest in Sheffield heard how Abbie, who had Down's syndrome
and a hole in her heart, received an inaccurate prescription from
the Sheffield Road practice.
Coroner Chris Dorries heard differing accounts of how the
wrongly-marked prescription was generated by receptionist Julia
Dransfield and signed by GP Dean Warwosz.
Mr Dorries concluded the evidence of neither of these key
witnesses was reliable, adding: "The exact circumstances in which
the prescription was signed by a doctor remain unclear."
The coroner said he will write to the Chief Medical Officer to
ask him to investigate whether it could be made impossible for
surgery receptionists to generate anything other than repeat
prescriptions.
In a narrative verdict, Mr Dorries said: "The overdose arose
because a prescription was wrongly issued on April 24, 2006, which
increased Abbie's medication tenfold.
"The prescription was wrongly generated on the surgery computer
as a result of established or recognised procedures not being
followed within the practice."