FAILURES to double check medication being handed out at a Spalding doctors’ surgery led to a patient being given six-times the prescribed dose of a controlled drug.
A “frazzled, stressed and overworked” dispenser at Church Street Surgery did not notice she had picked up the wrong box – a mistake also missed by a barcode scanning machine and a community nurse.
John Bradford-Fawson (76), of Northgate, Pinchbeck, died three days after taking a 60 milligramme morphine sulphate tablet instead of a ten milligramme tablet.
However, at an inquest at Spalding Magistrates’ Court on Friday, coroner Maureen Taylor found that Mr Bradford-Fawson (76) died of natural causes.
The inquest heard how Mr Bradford-Fawson had been admitted to Pilgrim Hospital, Boston, on February 11 last year after falling and fracturing a hip. He spent seven months in hospital after suffering from a number of complications.
John Watson was a consultant orthopaedic surgeon at the hospital at the time. He said Mr Bradford-Fawson had not been making progress and this had delayed his discharge.
Mr Watson said Mr Bradford-Fawson, who suffered from dementia, had been a “difficult” patient.
His condition deteriorated but he was discharged at the beginning of September.
When he returned home, Mrs Bradford-Fawson called the Church Street Surgery to arrange a home visit. GP and surgery partner Dr Janarthanam Anand Babu visited on September 3. He said Mr Bradford-Fawson was alert and responding to commands but suffering from multiple bed sores. Further pain relief was prescribed.
However, Dr Babu was called back again after a district nurse found the pain relief was not effective. A further call was made on September 8 by Mrs Bradford-Fawson, who said her husband seemed to be in a lot of pain.
Dr Babu said he advised Mrs Bradford-Fawson to call 999 but she was “reluctant” after his earlier hospital experience.
He prescribed ten milligrammes of morphine sulphate tablets on September 9 but dispenser Lynn Coddington mistakenly gave out 60 milligramme tablets instead.
The drugs had not been checked by a second member of staff and a dispensing machine, which scans the barcode on the drugs to match it to the prescription, failed to flag up an error.
Dr Babu told the inquest she went into his room “very tearful” the following day when she realised her error.
Community nurse Carole Rickard also failed to spot the discrepancy between the printed label and the packet of drugs when she visited Mr Bradford-Fawson at home the night he took the tablet.
Dr Babu said he visited Mr Bradford-Fawson the following day and found him drowsy and with low blood pressure. He called a consultant at Pilgrim Hospital for a second opinion, who said to let him “sleep it off”.
Mr Bradford-Fawson’s condition deteriorated further in the following days. He was given further pain relief but died at home on September 12.
Professor Peter Vanezis, who carried out a post mortem, said the primary cause of death had been bronchial pneumonia.
The inquest heard how it had been an “exceptionally busy day” at Church Street Surgery when the wrong drugs were dispensed.
Ms Coddington said she believed the barcode scanning machine was right when no error message came up.
“I have asked myself about it a thousand times and I do not have any answers,” she said.
Controlled drug procedures at Church Street Surgery have since been changed.
Solicitor Mark Fielding read out a statement on behalf of Mr Bradford-Fawson’s family.
He said Mrs Bradford-Fawson was “relieved” the inquest into her husband’s death was over but she found it “very sad and distressing” that he was taken from her because of what she saw as a “catalogue of errors”.
Mr Fielding said Mrs Bradford-Fawson felt the NHS had let her husband down very badly but she took some comfort that Church Street Surgery had learnt lessons from it.
“She takes some comfort in knowing John’s death was not in vain,” he added.