NHS fails to curb lethal painkiller errors
Health workers made more than 1,300 mistakes involving the use of strong painkilling drugs in less than a year, resulting in at least three deaths and severe harm to two other patients.
Nearly one in five dosage errors involving morphine, diamorphine and similar opiate drugs resulted in some harm to NHS patients.
Figures released under a Guardian Freedom of Information request show mistakes in England and Wales continue at a high level despite the publicity that followed the Guardian’s revelation in May last year about the death of David Gray.
The 70-year-old died at his home in Cambridgeshire when he was injected with a tenfold overdose of diamorphine by Daniel Ubani, a locum GP who had flown in from Germany that day.
The official report into the incident last month revealed two other GPs hired, like Ubani, by Take Care Now – a now-defunct company that was then providing some out of hours services for the NHS – had been involved in non-fatal diamorphine overdoses the year before.
The breakdown of the new figures suggest lessons have not been learned, with little change in the numbers of people harmed by medication errors involving this class of drugs despite several official safety warnings.
David Gray’s son, Rory, called the new figures “unbelievable”. “Taken at face value [they] suggest nothing has been made safer with regards to opiate medicines at all. Whilst there is no accountability then it seems there will continue to be no effective measures put in place to stop these unnecessary and avoidable deaths.”
The charity Action against Medical Accidents (AvMA) said the statistics were shocking and “confirm our worst fears about not implementing patient safety alerts”.
In its own research, coincidentally being published at the same timetoday, the organisation accuses hospitals and other care providers of killing and injuring patients by not complying with official directives from the National Patient Safety Agency (NPSA) intended to protect those receiving care.
However, safety experts point out that the numbers of patients being treated by such drugs is rising, so the proportion of mistakes may be going down.
Both the NPSA, established in 2003 to help the NHS learn from its mistakes, and the Care Quality Commission (CQC), the health service regulator, insisted things were improving, although notifying the two bodies over drug and other errors that resulted in death or severe harm only became mandatory on 1 April this year.
The NPSA received a total of 4,223 cases involving opiate drugs between November 2004 and June 2008. Of these, 3,338 were recorded as causing no harm, 629 low harm, 242 moderate harm and four severe harm. Five patients died. There was insufficient data on five other cases. Figures from May 2009 to April this year show 1,329 cases, 1,078 said to have resulted in no harm, 179 low harm, 67 moderate, and two severe. Three patients died.
Linda Hutchinson, CQC director, said: “Unfortunately we will never be able to eliminate human error from healthcare, but the risks can be minimised. That is why it is so important that NHS trusts and other health providers report incidents, thoroughly investigate them and make changes to stop the same mistakes happening again. They should also implement changes as a result of safety alerts. Had Take Care Now done this, it is possible that Mr Gray would still be alive today.
“The increase in reporting is a good thing. We often find it is the NHS trusts reporting a high number of incidents that are doing a better job of investigating them and taking action to prevent them happening again.”
The NPSA said its reporting system was one of the most sophisticated in the world: “We gather patient safety incidents, analyse them for trends and use these as a platform on which to produce patient safety alerts and guidance for the NHS.
“It is evident the reporting culture in the NHS has improved with over 1 million incidents [relating to drugs, medical and surgical procedures] reported each year. The majority of incidents reported to us in relation to diamorphine and other opiates result in low or no harm to the patient. In addition, most of these do not relate to mis-selection of injectable diamorphine or morphine.”
The agency believed it was now told of the “vast majority” of serious incidents.
The revelations come as hospitals and other providers of care are accused by AvMA of killing and injuring patients by not complying with official directives from the NPSA intended to protect those receiving care. Dozens of hospitals, mental health trusts and primary care trusts are failing to implement patient safety alerts from the agency, despite the Department of Health writing to them reminding them to do so.
Some 29 NHS organisations had not put at least 10 alerts into action by 7 June, on issues such as drugs and oxygen, even though with some, the deadline for compliance was several years earlier, according to AvMA: “It is impossible not to conclude that lives are being put at unnecessary risk and it is likely that avoidable injuries or deaths are still being caused as a result of trusts not complying,” it says.
Public health minister Anne Milton said: “Across the NHS there must be a culture of patient safety above all else. We have set out how we intend to free NHS staff from central control and targets that are not clinically justified to allow them to focus on what really matters – reliable, effective and above all safe care for each patient.”
Tags: Care Quality Commission, Health Professionals, NHS Deaths, NPSA, Risk of Drugs