It was a typically busy night in the regional neonatal intensive care unit. The nursing staff informed a junior doctor that an infant's intravenous cannula had “tissued.” The doctor inserted a new cannula but, on attempting to flush the cannula with water, it was obvious that the cannula had been sited extravascularly. > Crucial statements were littered with inaccuracies, inconsistencies, and blatant errors of fact While the doctor collected equipment for another cannulation attempt, the infant had a profound cardiorespiratory collapse from which he could not be resuscitated. An opened ampoule of intravenous phenytoin, intended for another patient, was found near to the deceased infant, raising the dreadful possibility that an erroneous administration of phenytoin had contributed to the infant's death. > Let us hope that the CPS will never again attempt to destroy the career of an innocent doctor The doctor who had attempted to replace the intravenous cannula was immediately suspended. The coroner …
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Kosalakumar Karunaratne (2002) studied this question.