VOTE: Procedures at St Richard’s Hospital tightened after OAP death

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ST Richard’s Hospital has apologised for a ‘terrible, one-off accident’ which resulted in the death of a pensioner.

Last week, as reported in the Observer, an inquest found that Joan Dixon, 77, of Findon, near Worthing, had died at the hospital on October 19, 2010, from a large overdose of heart medication, which had been prescribed for her by a junior doctor.

Since then the hospital has introduced a number of measures to ensure such an accident never happens again.

This week Phillip Barnes, medical director of West Sussex Hospitals NHS Trust, said: “Our thoughts are of course with Mrs Dixon’s family. We have expressed our condolences to them in person, and we have offered to meet with them again if they wish to do so.”

The hospital said it had strengthened its safeguards since the accident happened two years ago in the Ashling Ward.

Dr Barnes added: “We are all sorry that a terrible, one-off accident such as this could have happened at our trust.

“We have a strong record on patient safety, and a strong safety culture, and nothing comparable had happened before, or has happened in the two years since.”

At the inquest last week, West Sussex coroner Penelope Schofield said in her narrative verdict: “The safeguards in place at the time were inadequate to prevent this unfortunate chain of events from occurring. 2.5 milligrams of digoxin was administered to Mrs Dixon, which was ten times the intended dose.

“Mrs Dixon sadly died, having suffered a cardiac arrest as a result of digoxin toxicity.”

Digoxin is used to treat a number of heart conditions.

Mrs Dixon was originally in hospital for breaking her hip in September of that year.

She had previously been sectioned because of mental health problems that year, and her daughter Carolyn said that when she visited her mother in hospital, she felt the care she was being given was not taking into account her mental state.

According to her daughter, Mrs Dixon appeared ‘dishevelled and confused’ when she visited her the weekend before her death.

Prashen Pillay, who prescribed the overdose, spoke last week of his sorrow at the accident, and apologised to the family.

He also said that when he returned to work he would ensure that, not only did such an accident not happen again, but that junior doctors were given far more support than he says 
he received.

Following the coroner’s verdict, Dr Barnes also added: “Safeguards have been strengthened in the last two years.

“We have strengthened all of our medicines management processes including additional training for nursing and junior doctor staff and changes to how we handle stock drugs on different wards.

“In addition junior doctors are now assessed for prescribing competency, and we have ended the use of potentially-confusing abbreviations for quantities on prescriptions.”

At the inquest Saffron Mawby, head of pharmacy, said: “We did a review of all areas within the organisation that hold digoxin as stock.

“Digoxin injection is no longer a stock item on Ashling.”

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