Source · Prevention of Future Deaths

Dorothy Robinson

Ref: 2014-0374 Date: 13 Aug 2014 Responses identified: 1 / 1 View PDF

A persistent risk of prescribing errors due to unaddressed patient intolerances/allergies remains, compounded by the absence of a crucial electronic prescribing system with no clear implementation timeline.

Date 13 Aug 2014

56-day deadline 8 Oct 2014 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

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During the inquest heard evidence that there remains a risk Of a prescribing error despite the steps taken by RUH to date_ have been advised that there is only one way to help prevent this and that Is through the electronic prescribing system referred to in the Action Plan to the Root Case Analysis was not told an date when the system will be introduced only that there was an understanding that it may take up to two years_ like to receive reassurance from the RUH as to the exact steps that are taken in relation to installing this system or indeed any other system which can help prevent a prescription error was advised that the millennium system is not proposed to be used in this way Therefore in summary please advise of the steps planned to be taken to prevent a prescription error across the Whole of the Trust in all areas of medicine due to a previous intolerancelreaction/allergy:

Responses

1 respondent

Royal United Hospital Bath NHS / Health Body

15 Oct 2014 PDF

Action Planned

The Trust is investing in a replacement patient administration system and learning from other hospitals implementing e-prescribing. They have strengthened existing processes and are implementing an electronic prescribing module for discharged patients in March 2015, mandating entry of allergies/adverse reactions. (AI summary)

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Dear from

In specific specialties, such as Oncology and Haematology there is an electronic prescribing system that mandates the entry of an allergy adverse reaction at the point of prescribing: This system is called ARIA and is referred to in the investigation report. investment has been made to develop ARIA to ensure that it covers all out-patients and in- patients receiving the complex medicines regimens prescribed in Oncology and Haematology: This will take a further 12 _ 18 months to complete_ An electronic prescribing module for patients being discharged with medication from the RUH has been developed and will be launched in March 2015. An earlier system was tested Trust wide in 2013 but required revision to capture all the safety features, an example of testing and refining of e-prescribing is essential to avoid solving one problem whilst creating another: This system will also mandate the entry of allergiesladverse reactions in the discharge letter that goes to GPs. Currently this is done manually if an adverse reaction occurs in hospital: The transition from paper-based health records to electronic systems at the RUH is gradual and lengthy process. change of this enormity can present some risks, but these risks are managed through the Medical Records Users Group, a body that is led by one of the Trust's most senior clinicians and which works closely with the Clinical Informatics Group and Information Technology teams _ No system, whether electronic or not, can ever reduce the risk of prescribing a medicine for a patient who is intolerant of it to zero. hope have demonstrated to you; though; the actions we have taken to mitigate that risk as much as we can If you would like to discuss the contents of this letter further; both myself and| Medical Director would be happy to meet with you.

Report sections

Investigation and inquest

On 4lh February 2014 commenced an investigation into the death of Dorothy Joan ROBINSON, aged 79. The investigation concluded at the end of the inquest on 11th August 2014 The conclusion of the inquest was that the medical cause of death should be recorded as la Respiratory failure Ib Diffuse alveolar lung injury Ic Busulphan treatment for myeloproliferative disorder (thrombocythemia) Pulmonary emboli and infection The conclusion gave was accidental death contributed to by neglect

Circumstances of the death

Mrs. Robinson had a disorder which required treatment and over the years she had at times received Busulphan for this During 2006 she was seen by a Iwith difficulties breathing-felt that her symptoms may be due to the Busulphan and he wrote a letter to her consultant advising that consideration should be given to an alternative drug: Her consultant; said that at the time in 2006 she saw the letter and she wrote on it From 2006 to 2012 Mrs. Robinson did not receive Busulphan; In late 2012 she was again given Busulphan by Iho said that in 2012 she had no recollection of the letter and if she had she would not have prescribed Busulphan In December 2013 Mrs_ Robinson's breathlessness became a ~concern; she developed pneumonitis due to the Busulphan she was admitted to hospital on 18' January severely unwell and sadly died on 275 January 2014_ It is clear that the death was due to an adverse drug reaction causing the pneuomonitis It also appeared that there was & failure to remember the previous intolerance recorded in the records by the consultant when re-prescribing Busulphan or to consider why the drug had been previously stopped before re-prescribing it using

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action:

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Report details

Reference: 2014-0374
Date of report: 13 August 2014

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 8 Oct 2014 (estimated).

Sent to

Royal United Hospital

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.