Medicine errors at Good Hope lead to deaths

A MEDICATION error which killed a Good Hope patient was one of six 'serious untoward incidents' at the hospital, according to an investigation.

The incidents, covering a range of procedural mistakes, are listed in a report by the Care Quality Commission (CQC).

The Commission began reviewing the safety of patients at the request of Heart of England Foundation Trust (HEFT) which runs three hospitals, including Good Hope.

The Trust confirmed this week that there were four fatal medication errors at its sites during the period under investigation – March 2007 to June 2009.

One came at Good Hope, where a second patient survived a drugs mistake. The remaining three deaths happened at Heartlands Hospital, Birmingham, where a non-fatal overdose was given to a baby.

Lisa Dunn, hospital director at HEFT, said: "We deeply regret that these incidents occurred and would again like to apologise to the patients and relatives of those affected. We have invited those affected by medication errors to work with us on an independent review surrounding prescribing and administrating medication within the trust."

The final CQC report actually mentions five fatalities, but a HEFT spokesperson said the figure was one too many and a new report would address the oversight.

Of the Good Hope fatality, HEFT would only say that it involved insulin.

Victims of the fatal mistakes at Heartlands include Sutton cancer patient Paul Richards. In 2007, he was given a lethal overdose of amphotericin, a drug designed to combat the side effects of cancer treatments.

In addition to medication mix-ups, the CQC has been reviewing a series of procedural errors which it brands Serious Untoward Incidents.

It reports 27 across HEFT sites and they range from junior staff not raising concerns quickly enough to gaps in training. Six occurred at Good Hope.

'A cluster' of serious incidents within the paediatric service has also been identified at HEFT. However, the CQC concludes that it has no 'immediate concerns' about the safety of HEFT patients.

Paul Richards' widow, Lisa Richards-Everton, is leading a campaign which calls for a review of the way drugs are administered across the NHS.

She said she was 'not surprised' by the numbers, predicting increases until procedure was overhauled.

She also criticised the report for simply collating numbers, instead of breaking down the details of incidents.

"It is misleading, the report has nothing to do with medication and the deaths are just mentioned in passing. I'm insulted.

"They should never have put the deaths in the report if they fail to investigate them in it."

She said that HEFT had written to her as pledged, asking for her input. "I said I'd be willing to help and I'm now waiting to see what happens next.

"My only concern is that I find it difficult to go anywhere near the hospital because I have so many traumatic memories."

The CQC's review praises HEFT for launching internal investigations, but says more work is required.

Andrea Gordon, CQC director, said: "We found there were some improvements needed with ensuring action plans were specific and were consistently implemented following incidents.

"The Trust also recognised this, and was already working to improve."

Formally closing the case, she added: "The commission did not have any immediate concerns relating to safety of patients."

HEFT's Lisa Dunn said the Trust contacted the CQC due to the incidents' 'very serious nature'.

"To further enhance patient safety and in keeping with our commitment to it, we are commissioning a further external review of our medicines management, which was cited in the report as the most common cause of incidents."

For more on the campaign by Paul Richards' widow, see page ten.