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Ilkley patient at Bradford hospice given morphine overdose
7:00am Wednesday 6th March 2013 in News
A hospice nurse twice gave an elderly patient more than four times the prescribed dose of morphine, an inquest was told.
Salma Nawaz wiped tears from her eyes as she described her busy Boxing Day shift at the Marie Curie Cancer Care centre in Bradford when she was looking after 69-year-old Kenneth Rowland.
She told the hearing in Bradford yesterday she had been distracted by Mr Rowland, who kept talking to her while she was preparing his medication – so much so that she had to take the drugs trolley out of his room into the corridor to do it.
“He kept talking to me. To be honest with you I can’t recall how I calculated his medication,” she said.
It was only after a shift change that the overdoses were noticed.
Mr Rowland, of Sunset Drive, Ilkley, was supposed to have 1.75ml of Oramorph but instead had been given two lots of 7.5ml of the drug.
Staff nurse Nicola Ward found him unresponsive in his armchair.
On-call consultant Dr Sarah Holmes prescribed an antidote over the phone and within 15 minutes Mr Rowland had come round but was feeling awful and panicking, said Miss Ward.
After a brief improvement Mr Rowland, who had an undiagnosed cardiac condition and had been admitted two days before with a chest infection, deteriorated and died the next morning.
Findings from two post-mortem examinations were conflicting, the inquest heard. Both morphine toxicity and bronchial pneumonia were given as causes of death.
Mr Rowland, who had been exposed to asbestos during his working life at Spooners engineering firm in Ilkley, had been diagnosed with malignant mesothelioma in 2010.
Pressed to give her own opinion on the cause of death, Dr Holmes said she felt there were several factors but Mr Rowland had developed pulmonary oedema which can be a rare side effect of the antidote he was given.
But she said: “I can’t be certain the antidote was involved at all. He could have developed it suddenly at any time.”
Dr Holmes also said sudden deaths of people as unwell as Mr Rowland were not uncommon and listed his pulmonary oedema as the main cause, his bronchial pneumonia and mesothelioma.
The inquest heard that leading up to his death after the antidote, the pensioner had not been showing any signs of opiate toxicity.
An internal investigation was held at the hospice after Mr Rowland’s death two years ago and Marie Curie had brought in changes to make drugs rounds and hand over procedures more efficient, the hearing was told.
Assistant Deputy Bradford Coroner Dominic Bell said Mr Rowland’s family bore no malice against the nurse, who was initially the subject of a police investigation which was discontinued when gross neglect or intent could not be proved.
He adjourned the hearing until today when he will record a narrative verdict.