Digital prescription service introduced after avoidable death of hospital patient

Hospital bosses are hopeful a new digital-based drug prescribing system will help avoid a repeat of an avoidable death.

A 57-year-old man died nine days after undergoing an elective surgical procedure, and was due to be discharged the next day.

However, soon after complaining of calf pain he collapsed and died from a pulmonary embolism, after a clot in his leg travelled to an artery in his lungs.

It was subsequently discovered that the patient had not been receiving Clexane – anti-clotting medication – for seven days.

It is that failure of clinical staff not noticing the medication had not been reinstated that bosses hope will help to be picked up with the introduction of an electronic prescribing and medicines administration (EPMA) function.

Suzanne Harksworth, an associate director in surgery, described the impact the death of the patient had on staff in an emotional presentation to staff at Broomfield Hospital on Wednesday, March 11.

She said: “The team and myself and everyone indirectly involved and directly involved understandably were completely devastated by what we knew was our failure.”

In a video presentation aimed to focus minds on what can happen, she added: “A patient died unexpectedly the day before he was due to be discharged home from one of our surgical wards.

“The team attending immediately identified they felt this patient had probably died from pulmonary embolism.

“And on review of his drug charts we could all see the patient, despite it being prescribed post operatively, had not had Clexane administered for seven days.

“The reason for that was a decision made on day two due to a large amount of blood in his drain to omit the dose for three days.

“Unfortunately following those three days the nursing staff continued to omit the Clexane dose and the patient developed leg pain and collapsed and died in the bathroom with his brother in attendance.”

She said the shock of this for nursing staff, the consultant-led team, therapists and other colleagues had stayed with them for a long time and continues to.

“This 57-year-old man came into our care to have an elective surgical procedure and due to our failures in ensuring his safety and prevention of known complications of surgery which are life-threatening he died,” she added.

“When we met with his wife, daughter and son-in law, we attempted to explain why the team had not on a daily basis reviewed his drug chart, reassessed the need for Clexane, questioned at any time the fact it had not been given. If we had and reinstated the treatment he would have been with us today.

“The most heart-breaking part of that was when his wife asked us ‘if on the day I asked the nurse on the tea round why my husband wasn’t getting an injection like everyone else and if I had challenged her more, would he still be alive?’

“I had to say to her that was not her job. It was our job and we have failed in that job.

“I don’t want anyone else to have to sit in front of a family and say that and I hope that by my talking today this story will stay with you as it will stay with me and the nurses, consultants and therapists who were involved in that patient’s care because it will certainly stay with his family.”

Martin Callingham, chief information officer at Mid Essex Hospitals Trust, said funding was in place for a roll  out of e-prescribing at Basildon, while  a rollout at Mid Essex was being planned for next year.

He said: “E-prescribing is one of those critical bits of software we are looking to implement. We have the funding and plans to roll that out from Basildon.

“There is prerequisite around stock control which will help with funding to make it into a group model and we are putting in a business case to put the EPMA in towards the end of next year for Mid Essex.”

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Piers Meyler

Local Democracy Reporter