Nurse involved in giving two babies lethal doses of cyanide medication at London hospital still allowed to practice

7 August 2024, 08:00 | Updated: 7 August 2024, 08:24

A nurse involved in giving two premature babies lethal doses of cyanide medication at a London hospital is still allowed to practice, LBC can reveal.

Ptimmy Bonyad admitted she failed to do proper checks when she helped prepare and administer Sodium Nitrate – mistaking it for Sodium Bicarbonate – to newborns Elena Ali and Sunny Parker-Propst, which killed them both within weeks of each other at Chelsea and Westminster Hospital in 2020.

An inquest jury last month found a verdict of accidental death by neglect for baby Elena and unlawful killing for baby Sunny, laying bare a catalogue of errors at the hospital.

But just a week later Elena’s grief-stricken mother, Selina Ali, was shocked to receive a letter from the Nursing and Midwifery Council (NMC) – seen by LBC - explaining that Ms Bonyad could continue practicing.

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Mrs Ali, 39, from Kingston, told LBC that nobody has been held to account for the “catastrophic” failures leading to her daughter’s death and that she fears for the safety of other patients treated by Ms Bonyad.

She called for root-and-branch neonatal reform in the UK – describing the public bodies who regulate healthcare as ineffectual – and is due to meet Health Secretary Wes Streeting alongside a group of other parents who have lost children.

It comes after Mr Streeting described the Care Quality Commission (CQC) – which regulates healthcare providers in England – as not fit for purpose after an independent review revealed “significant internal failings” were hampering its ability to investigate services.

Mrs Ali hit out at the CQC for failing to act against Chelsea and Westminster NHS Trust or make any recommendations for its improvement after a year-long investigation, which delayed the inquest, and has urged the body to reconsider its findings.

The CQC told LBC that it found no evidence of service-wide failures at the Trust and that it would not be reviewing its investigation.

Speaking to LBC, Mrs Ali said: “It was really upsetting for me to get that letter (from the NMC).

“You’d think that someone who's been involved in two cases where babies have died and made a catalogue of catastrophic, basic errors, wouldn’t be able to work in the industry anymore.

“So, it’s hard to understand what regulatory bodies like the CQC and the NMC do.

“I’ve been left with this feeling that nobody has been held accountable.”

The letter explained that the NMC had lifted the interim restrictions which it placed on Ms Bonyad, preventing her from administering medication without supervision, when Mrs Ali and the Trust’s chief nurse referred her fitness to practice to the regulator in May 2021.

In a statement to LBC the regulator admitted it “temporarily restricted” Ms Bonyad’s practice during its investigation and that the nurse had completed undertakings ensuring she was now safe to continue working without restriction.

The inquest heard how Ms Bonyad mixed the infusion in the case of baby Elena and acted as the ‘second checker’ in the case of baby Sunny – meaning it was her responsibility to check the medication.

She admitted that she failed to follow a policy of checking the vial at eye level and did not look at the label.

Mrs Ali told LBC that she also made a referral to the NMC for a second nurse involved in administering the drug to baby Elena but that she has since left the UK, meaning she is no longer in the jurisdiction of the regulator.

Mrs Ali has joined the Maternity Safety Alliance, a group set up by parents Jack and Sarah Hawkins whose daughter Harriet died due to poor care at Nottingham City Hospital.

Their experience led to a public inquiry launched last year into over 1,700 incidents at the Nottingham University Hospitals Trust – which became the largest maternity review in NHS history.

Mr and Mrs Hawkins are leading calls for a wider inquiry into neonatal care across the UK and say they and a group of parents including Mrs Ali are planning on meeting with the Health Secretary soon.

They told LBC: “We are so sad to hear these latest stories, yet we are in no way surprised.

“The CQC is charged with making sure hospitals and other health and social care services are safe - yet we had nothing useful from them.

“For there to be so many avoidable baby deaths, invariably from the same basic failures in care, and for the CQC to frankly take no action against either hospitals or staff has, we believe, reinforced the ‘nothing to see here' attitudes of clinical staff, managers, hospital bosses and their legal teams.”

Their comments come after research by neonatal charity SANDS found over 800 babies could have been saved with better care last year and that NHS England is on course to miss its 2025 target to reduce still births and neonatal deaths by 50 percent.

Suzanne White, head of medical negligence at legal firm Leigh Day, which represented the family of babies Elena and Sunny at their inquest, said there are still questions to be answered about how cyanide medication ended up on a neonatal intensive care ward.

The inquest heard how the hospital pharmacy had mistakenly stocked a vial of sodium nitrate on the ward but that an internal investigation failed to uncover who was responsible.

The hospital’s chief pharmacist admitted that there had been a “complete and total” failure in checks.

Ms White told LBC: “It’s a failure for the CQC not to punish the Trust – there should have been other repercussions which were more draconian.

“They should have been fined - the CQC didn’t even make any recommendations.

“I think [Wes Streeting] is completely right about the fact that it’s ineffectual.

“It’s got to have some teeth or else nothing is going to change.

“I’m concerned about the NMC and its effectiveness - again such a serious failure by a nurse should mean that she cannot practice.”

In a statement, the CQC said their “deepest condolences” remain with babies Elena and Sunny’s families.

They said: “CQC have legal powers to prosecute provider level failings. However, we do not have legal powers to prosecute for individual clinician failure.

“After a thorough review of all the evidence we did not find sufficient evidence of provider level failure to give grounds to pursue prosecution.

“We also sought assurances from the Trust on what improvements they had implemented to avoid the same thing happening to other babies in future.

“Our priority is always the safety of people using health and social care services, and if we have concerns, we will not hesitate to take action in line with our regulatory powers.”

Lesley Watts, Chief Executive of Chelsea and Westminster Hospital NHS Foundation Trust said: “We took immediate action to put measures in place to prevent such tragic incidents from happening again.”

Paul Johnson, Deputy Director of Professional Regulation at the NMC told LBC: "We extend our deepest sympathies to the families of Elena and Sunny. We temporarily restricted this nurse's practice while we investigated their case.

“Our case examiners found that there was a case to answer and issued undertakings which the nurse needed to fulfil as a pathway back to safe practice.

“Those undertakings have now been fulfilled and the nurse is now able to resume their practice without restrictions."

Ms Bonyad has been approached for comment.