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A London pharmacy and medical practice have failed to block a mother’s claim over an inadvertent morphine overdose that led to the death of an infant receiving palliative care in 2020.

On Friday, October 23, Judge Holmes of the central London county court rejected applications to strike out or grant summary judgment against Esther Boate’s claims against Millennium Pharmacy and Vassall Medical Centre. 

This followed a September 25 hearing concerning Ms Boate’s claims of psychiatric injury relating to the circumstances of her nearly four-month-old daughter Juanita’s death on September 9, 2020.

Juanita Boate Nti was born on May 12, 2020 and diagnosed with complex untreatable congenital diseases. She received palliative care from July 2020, which in part involved her parents administering a morphine solution via naso-gastric tube.

In late August 2020, a new supply of morphine was prescribed and dispensed on Ms Boate’s request. The surgery’s prescription stated ‘10 milligrams over 5mls’ and then below that, '100 micrograms per ml solution, 120 micrograms 6 hourly'. A coroner later described this as confusing.

The pharmacy dispensed the higher concentration without stipulating the volume to be administered. The inquest found that the pharmacist had failed to notice the instructions on the second line.

Esther Boate administered the supplied morphine on September 3, leading to Juanita’s immediate collapse after she received a dose approximately 20 times higher than was intended.

She died in hospital six days later. The cause of death was later attributed to Townes-Brocks syndrome with tracheal stenosis and complex congenital heart disease following accidental morphine overdose.

In her secondary victim claim, Ms Boate says she has suffered from post-traumatic stress disorder and severe depressive disorder as a result of these events.

Barristers representing Millennium Pharmacy and Vassall Medical Centre argued that the circumstances leading to Juanita’s death did not amount to an accident as defined by the Supreme Court in a landmark 2024 ruling, as the act of administering morphine was one that had been performed by Ms Boate a number of times prior to September 3, 2020. 

Ms Boate’s barrister argued that the case was not suitable to be struck out or to be resolved without a trial through a summary judgment and that it should be considered on the evidence. 

Judge Holmes said there was “considerable force” in the defendants’ position but found there was a real prospect that the administration of the morphine could qualify as an accident under the 2024 Supreme Court ruling. 

The judge did not make a determination on whether the defendants were liable or whether Ms Boate had established the psychiatric injuries she claims to have suffered. He ruled only that her claim has a real prospect of proceeding and should not be dismissed without a trial. 

In 2023, a coroner raised concerns that a lack of menu options for morphine dosages on the EMIS prescription system may have played a part in the communication issues that contributed to Juanita’s death, as 10mg/5mls was the only strength listed on the system. The inquest also found that the strength and volume “were not clearly communicated” on the treatment plan sent by the hospital to the GP. 

London Inner South senior coroner Andrew Harris said in his August 2023 report to prevent future deaths: “Whilst both GP and pharmacist made errors in clinical practice and did not contact each other, the error would not have occurred had another strength of morphine been a choice on EMIS.”

EMIS subsequently made changes to how morphine dosages appear on its database. 

Millennium Pharmacy and Vassall Medical Centre have been approached for comment.