A coroner has ruled that a woman died after a mix-up occurred with an electronic prescription, resulting in the patient taking incorrect medication prescribed for an infection.
David Urpeth who is the assistant coroner for South Yorkshire West, stated that another prescription error death would happen in the future, were action not taken to prevent it.
Sandra Dawn Scott was prescribed trimethoprim to treat a urine infection whilst attending the Royal Hallamshire Hospital on the 18th of April, 2019. On the same day, her GP reviewed results of an earlier urine test and realised that her infection would not be cleared up with trimethoprim and thus changed the prescription to amoxycillin – an alternative antibiotic.
The prescription was then issued by the Electronic Prescription System (EPS) to her nominated pharmacy. To ensure that future antibiotics were not reissued on her repeat prescription, the GP then amended the electronic system after her appointment at the clinic.
Unknown to the GP, however, this meant that it blocked the amoxycillin prescription from being downloaded at the pharmacy. The only EPS prescription available to the pharmacy team was the prescription for the original, ineffective antibiotic – trimethoprim.
Two days later on the 20th of April 2019, Scott’s urine test results were returned to the hospital but remained unreviewed.
Scott was admitted back to hospital with deteriorating symptoms on the 22nd of April. The error was picked up on and she received the correct treatment from then on, but her condition worsened the following day and she died on the 23rd of April.
The inquest revealed that the GP’s colleagues were also unaware of this caveat with the electronic system, meaning that other medical professionals may also not know about it. It was ruled that the patient would’ve lived had she received the withheld medication, or had it corrected by the results of her final urine test results on the 20th of April.
This report was circulated to the GP’s practice, the Royal Hallamshire Hospital, the CCG (Clinical Commissioning Group) and the chief executive of NHS Digital, Sarah Wilkinson, demanding a response by the 2nd of January 2020 with a report detailing any action taken or proposed. This date has since been extended to the 20th of January, 2020.
The Healthcare Safety Investigation Branch (HSIB) had identified what it deemed to be a significant safety risk with the EPS system, after a patient – 75-year-old Ann Midson – died due to receiving two types of blood-thinning medication simultaneously.
The HSIB’s then-director of investigations, Dr. Stephen Drage, stated at the time:
“ePMA systems are a positive step for the NHS – research shows if implemented well they can reduce medication errors by 50%.
“Our report is highlighting the risks if e-prescribing is not fully integrated and doesn’t create the whole picture of the patient’s medication needs from when they arrive to when they return home. The more efficient the system, the better the communication is with the patients, families and between NHS services.
“The safety recommendations we’ve made are asking for national bodies to provide trusts with a blueprint for what a good system and implementation should look like. This will mean ePMA systems are used to their full benefit, reducing the risk of serious harm to patients.”
Kathryn Stitt of our Medical Negligence Team says:
“Having had success in obtaining compensation for clients, who have been wrongly prescribed medication, it is disappointing to hear these problems are ongoing. Death at the hands of negligence should never occur.
“Here at Oakwood Solicitors, we are determined to obtain justice for individuals and their families who have suffered as a result of errors made by healthcare authorities, especially Pharmaceutical companies.”
WHAT TO DO NEXT
If you’ve suffered as a result of an incorrect prescription, wrong pills supplied or medication intended for someone else entirely, contact us for a free initial consultation. Choose one of the methods to the right-hand side of this page, or call us on 0113 200 9720 to find out how one of our team can help you.
Article by Stuart Jones
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