KEY POINTS:
A second hospital death due to a drugs mix-up has been highlighted by a coroner.
Hastings coroner Chris Devonport found that a 76-year-old man at Hawkes Bay Hospital died from a large brain haemorrhage after being wrongly given a second dose of blood-thinning medication.
Mr Devonport's finding released yesterday followed a report by Wellington coroner Ian Smith released this week that found a medication mix-up at Wanganui Hospital contributed to the death of 62-year-old Canadian John Peter Taylor in 2006.
Mr Taylor was admitted to Wanganui Hospital with heart and kidney problems five days before his death. His health deteriorated after a nurse gave him another patient's heart medication.
In the case of the unnamed Hastings man, he arrived at Hawke's Bay Hospital on January 3 this year after suffering intermittent chest pains for three weeks, The Dominion Post newspaper reported.
After diagnosing him with angina, emergency department staff administered a dose of anticoagulant medication Enoxaparin.
Half an hour later the on-call acute medical team diagnosed him as having suffered a heart attack and started administering a course of the anticoagulant heparin intravenously.
Twenty minutes later the man's gums began bleeding and the medication was stopped.
Shortly before 9pm a CT scan showed that the man had suffered a large brain haemorrhage. He died early the next morning.
A review for the Hastings coroner by cardiologist Keith Dyson found that the change in diagnosis should have prompted staff to consider what medication had already been administered.
Heparin should not be given intravenously until at least 12 hours after the last dose of Enoxaparin.
Mr Devonport found there ``there was a clear lack of awareness of medical staff as to the levels of drugs administered to (the patient)' and made several recommendations concerning training, record-keeping and communication.
Hawke's Bay DHB acting chief executive officer Win Bennett said the man's death had prompted an extensive review and systems had been improved.
- NZPA
