Hospital managers have apologised to the relatives of a six-week-old baby who was fed liquid soap instead of medicine, after the Oxford Mail highlighted the case.
Megan Boswell, who was discharged from the John Radcliffe Hospital, Oxford, after a nurse gave her grandmother baby wash instead of a colic remedy for her, was re-admitted hours later with severe vomiting.
The Oxford Radcliffe Hospitals NHS Trust said it had tightened procedures to ensure the mistake was not repeated and said the agency nurse responsible was no longer working at the JR.
Megan's grandmother, Gina Boswell, 41, of Fieldside, Abingdon, said she was pleased the hospital was working to prevent it happening again, but hoped the nurse concerned was punished. She said: "The outcome could have been a lot worse. I could have given Megan a lot more of the soap or it could have been bleach."
Megan was admitted to the JR last week with a lung infection, after her mother Joyce Boswell, 20, of Lammas Close, Abingdon, took her to the GP.
ORH spokesman Helen Peggs said the bottle of baby wash, which was not toxic, had not been labelled.
She added: "We will make sure all labelling is clearer. We are also looking at whether the nurse should have agreed to the grandmother's request for medicine. She shouldn't have given any medicine without a doctor's authority and she should have documented what she did."
Trust chief executive Trevor Campbell Davis said: "I can only apologise to the family for the distress this has caused."
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