Doctor blasts hospital's drug systems after patient dies

4.00pm

Drug procedures at Palmerston North Hospital have been blasted by a doctor who says he has seen nothing like them in any of the countries in which he has worked.

Respiratory specialist Mike Hayhurst, giving evidence in Palmerston North Coroner's Court yesterday, said the hospital's labelling methods for treatment charts were "highly unsatisfactory".

He told the court he had worked in Scotland, England, South Africa and the United States but had "never seen a system such as that at Palmerston North Hospital".

Dr Hayhurst was giving evidence in the inquest into the death of 91-year-old Eileen Maud Anderson, at the hospital in April 2002.

Mrs Anderson was taken to the hospital on the evening of April 5, 2002, suffering a chest infection.

She was given medicine before it was agreed she could be released back to TeWhanau Rest Home.

However, when it became too late for her to be sent home, it was decided that she should stay overnight at the hospital. Her daughter was told to collect her after lunch next day.

In the intervening 12 hours, a drug treatment chart prescribing morphine was started for another patient but, due to the hospital's labelling procedure, Mrs Anderson's name was confused with that of the other patient.

The treatment chart was started with no name on it and a computer-generated label was incorrectly placed on the medication chart.

When her daughter came to collect her, it was decided Mrs Anderson's condition had deteriorated and she was admitted.

Mrs Anderson was subsequently administered five 100ml doses of morphine, a respiratory depressant.

Doctors attributed Mrs Anderson's drowsiness -- which Dr Hayhurst said was a side effect of the morphine -- to a pre-existing "cognitive impairment".

She never left the hospital again and was bedridden until her death on April 22.

Dr Hayhurst criticised the fact that drug-treatment charts were not readily available to doctors making rounds, and were often either locked in a room, on a trolley somewhere in the ward, or kept with nurses.

He did not become aware until April 10 that Mrs Anderson had been given morphine. He agreed with counsel for the family, Gordon Paine, that morphine could be "very dangerous" to someone suffering a chest infection.

He also took the opportunity, while giving evidence, to offer Mrs Anderson's family his apologies.

"May I take this occasion to say how terribly sorry I am that Mrs Anderson should have had this happen to her. This is the worst experience I have ever had in my medical career.

"I shall never forget Mrs Anderson."

In a preliminary decision, coroner Graeme Hubbard ruled Mrs Anderson died of a pulmonary oedema, secondary to cardiac failure, with underlying pneumonia.

His decision, due out in the next few days, is expected to make recommendations that MidCentral District Health Board modify its labelling procedures.

MidCentral Health chief executive Murray Georgel said his board would await the coroner's report and consider any recommendations in it.

"MidCentral Health conducted an investigation into the incident two years ago and made immediate improvements, with a view to minimising the possibility of it ever happening again," Mr Georgel said.

- NZPA