Hospice praised for trying to reduce chances of error happening again (From Bradford Telegraph and Argus)

Hospice praised for trying to reduce chances of error happening again

8:00am Thursday 7th March 2013 in News

A hospice in Bradford where a nurse twice gave an elderly patient more than four times the prescribed dose of morphine has acted “rigorously and constructively” to make sure the same error never happens again, an inquest was told.

Two nurses, instead of one, must give controlled drugs and changes have been made to how the drugs are stored and charted and how nurses and doctors are regularly trained and assessed on administering them.

Staff nurse Salma Nawaz, who has not worked at the Marie Curie Cancer Care Centre since the incident two years ago, wiped tears as she had described to the court how she was looking after Kenneth Rowland, 69, on Boxing Day, 2010.

She told the Bradford hearing she had been distracted by Mr Rowland.

“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 overdoses were noticed.

Once the error was spotted on-call consultant Dr Sarah Holmes prescribed an antidote and within 15 minutes Mr Rowland had come round.

Mr Rowland, admitted two days before with malignant meothelioma and a chest infection, deteriorated and died the next morning. The inquest heard that findings from two post-mortem examinations were conflicting.

Recording a narrative verdict, Mr Bell said he felt no other action was needed at the hospice.

He also said Nurse Nawaz had not sought to “excuse her error”.

In his verdict Mr Bell said on the balance of probabilities it was combination of pulmonary odema and broncho-pneumonia that were the “proximate” causes of Mr Rowland’s death.

He said there were a number of factors that caused the pulmonary odema.