Coroner Finds That Neglect Contributed To Death Of Mother Of Four
23 Dec 2009
An inquest in Birmingham has heard that a 64-year-old mother of four suffered an agonising death after a series of errors led to medical staff at a Birmingham hospital administering a highly caustic, deadly substance into her lungs.
The error at Heartlands Hospital happened when a junior pharmacy worker bought an unlicensed chemical solution ten times stronger than usual. The solution went unchecked by the hospital’s head pharmacist, a consultant physician and nursing staff.
Aidan Cotter (Birmingham Coroner) recorded a narrative verdict contributed to by neglect following the death of Rosemary McFarlane, from Kingshurst, Birmingham, on 22nd August 2008.
Now a medical negligence solicitor at Irwin Mitchell is demanding a full external investigation and for lessons learned from this incident to be shared with all NHS Trusts across the UK. Mrs McFarlane’s death follows a similar incident at the same hospital a year earlier when two chemotherapy patients suffered fatal overdoses, after receiving medication five times its normal strength.
During the two day hearing, the inquest was told how a junior pharmacy worker was asked to locate alternative medical supplies after the hospital’s regular supplier was unable to provide stocks. The worker ordered a new batch of Phosphate Buffered Saline (PBS) solution over the internet, failing to realise that the product was in fact ten times stronger than usual.
Concentrated PBS is sometimes used to preserve tissues samples in a pathology lab, but is not licensed for use on live patients.
On 12th August 2008 Mrs McFarlane underwent a routine bronchoscopy to investigate the cause of lung problems and was administered the highly toxic solution.
There is no antidote to the use of the concentrated solution, so for the next ten days Mrs McFarlane slowly succumbed to the chemical which caused her to suffer pneumonia and terminal respiratory distress.
Guy Forster of Irwin Mitchell Solicitors is representing the McFarlane family, and explained: “This was a nightmare scenario which had the most tragic of outcomes. Following the initial purchasing error, there were a number of occasions when the mistake could and should have been corrected. However, a series of successive failures by clinicians and nursing staff meant that the mistake went undetected until after the lethal solution was administered.
“An internal investigation carried out by the Trust launched identified that the systems that were in place were inadequate and basic checks were not carried out.
“Sadly, there have been previous fatalities at Heartlands Hospital following administration of inappropriate medication and we are concerned that lessons appear not to have been learned by the hospital. An external investigation would not only provide transparency but would ensure other hospitals could learn from the tragic mistakes made by this Trust, which - with its foundation status - is meant to be a shining example of best practice.”
Rosemary McFarlane, known as Marie by her family and friends, leaves behind her husband of 42 years, Ian. A mother of four, Mrs McFarlane also leaves behind five grandsons.
Speaking on behalf of the family, Mrs McFarlane’s daughter, Annemarie Tranter, said: “Whilst the inquest has provided us with many of the answers surrounding Mum’s death, the family remain angry that she was let down so badly.
“She suffered so much during those last ten days. She was never the sort of person who made a fuss or complained, but the pain was so bad that she was crying with agony and she told us that it felt like her chest was burning. Eventually she was unable to speak but you could tell by looking at her how much pain and distress she was in. It was heartbreaking watching her slowly deteriorate.
“Whatever happens in the future it’s too late for Mum, but we do hope that today’s inquest will mean lessons have been learnt so that no other family has to suffer as we have.”
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