22/10/2013
Guy’
’s and St Thomas’
’ NHS
Foundation Trust, London
When things go very
wrong….
Objectives
Understand
.... a hospital ‘on trial’
’
Patricia Snell and team
How things can go wrong
The importance of ‘acting’ on information
Where ‘human error’ might move to ‘negligence’
Organisation and individual culpability
Guy’s and St Thomas NHS Foundation Trust
DAC Beechcroft
University College Hospital, London
ISQua Edinburgh, October 2013
Our case today...
Uses real professionals
Doctor, pharmacist and nurse
Beachcroft solicitor who is well known to our
hospital and many other UK hospitals
Judge
Fictitious, but based on events that are
very real
The ‘players’
Narrator
The doctor
The pharmacist
The nurse
The hospital
-
Alice Oborne
Mark Kinirons
Paul Tunstell
Eamon Sullivan
Adrian Hopper
The ‘prosecuter’ The judge
-
Louise Wiltshire
Corinne Slingo
We start...
Mrs A
Young mother of 4 children < 10 years old
Runs her own design business
Husband is freelance journalist, specialising in medical
misadventure for tabloids
Setting
Acute teaching hospital, part of an Academic Health
Sciences Centre
General ward
We start...
Problems
Mrs A has been admitted for a routine operation
She has a known allergy to penicillin
Anaphylaxis years ago
‘Saved’ by London Ambulance Service
Admission to our Emergency Department
Developed a non life-threatening infection
Working diagnosis: pseudomonal septicaemia
Solution
Call the experts: Infectious Diseases team
1
22/10/2013
Guy’
’s and St Thomas’
’ NHS
Foundation Trust, London
The timeline
The timeline
5.15 pm
Seen by the Infectious Diseases team
New prescription – not stock on ward
Nurse was asked to give 1st dose immediately
6.15 pm
5.40 pm
Prescription sent to pharmacy, after closing time
6.20 pm
6.00 pm
Prescription and drugs sent back to ward
Injection was prepared by nurse
Administered to Mrs A
Mrs A goes in to anaphylactic shock. Emergency call
is sent
Resuscitation team arrive
6.45 pm
Mrs A declared dead
Internal investigation
Mrs A - despite known anaphylaxis, was
Pre - Inquest
Prescribed, dispensed and administered a medicine
(piperacillin with tazobactam or Tazocin®) that
contained a penicillin
Policies and Procedures had not always been
followed
There had been previous similar incidents
Delayed
Husband was admitted to hospital because of mental
state
Children were looked after by grandparents
Husband recovering, but still on medication
Wife’s business in difficulty because of economic
climate and she was the lead designer
Case was referred to Crown Prosecution
Service
Post Mortem
Histopathologist report found:
The Court
Charge
Acute hypersensitivity reaction
Prescribed penicillin the likely cause
Previous medical history
Timeline
Criminal
Trust – Corporate Manslaughter
Doctor – Gross Negligence Manslaughter
Pharmacist – Gross Negligence Manslaughter
Nurse – Gross Negligence Manslaughter
2
Guy’
’s and St Thomas’
’ NHS
Foundation Trust, London
22/10/2013
The Court
The process we will follow
‘Explore’ the issues – it will feel like prosecution
to our professionals!
There is no dispute concerning the facts
‘Prosecution’ will ‘sum up’
Judge will ‘advise’ the jury on legal issues
YOU... will be the jury
Our judge will pass a ‘sentence’ and comment
on the ‘learning’ from incidents like this
Dr Mark Kinirons
Consultant in Infectious Diseases
Prescribed piperacillin with tazobactam, Tazocin ®
3
22/10/2013
Guy’
’s and St Thomas’
’ NHS
Foundation Trust, London
The Hospital Allergy Procedure
Staff Guide to Safe Prescribing
Paul Tunstell
Principal Pharmacist
Pictures of props
Prescription
Front – with allergy documented
‘inside’
The prescription chart
where supply has signature
annotation
Prescribed piperacillin with tazobactam, Tazocin ®
Policy / procedure
Medicines policy
Allergy policy
4
22/10/2013
Guy’
’s and St Thomas’
’ NHS
Foundation Trust, London
The Hospital Allergy Procedure
Staff Guide to Safe Prescribing
Eamon Sullivan
Matron at time of incident
Nurse’s Entry in the Clinical Record
Prescribed piperacillin with tazobactam, Tazocin ®
5
22/10/2013
Guy’
’s and St Thomas’
’ NHS
Foundation Trust, London
Staff Guide to Safe Prescribing
The Hospital Allergy Procedure
Adrian Hopper
Chief Operating Officer
6
22/10/2013
Guy’
’s and St Thomas’
’ NHS
Foundation Trust, London
Previous incidents
Eileen Oliver
Surgical patient needing admission to ICU
Trust allergy policy excerpt
Presentation at meeting open to all staff
Other no-harm ‘green’ incidents
Learning + Actions from these incidents
Previous message shown on all
hospital computers
Orange allergy stickers on all
inpatient charts
Put on by the person who first starts the medication chart
PENICILLIN ALLERGIC
Penicillin type drugs include: co-amoxiclav (Augmentin),
meropenem, Tazocin
Separate storage of penicillins
“We are what we repeatedly do.
Excellence, then, is not an act but a habit.”
Aristotle, 384-322 BC
7
22/10/2013
Guy’
’s and St Thomas’
’ NHS
Foundation Trust, London
Still testing changes
New prescription chart
Hand held patient allergy record
Warnings through electronic drug cabinets
And evaluating these
The best doctors
Even thesometimes
best doctors
make the can
worst
make
mistakes
the worst
mistakes
Alan Milburn
Alan Milburn visiting
Guy’s Hospital
“We are what we repeatedly do.
Excellence, then, is not an act but a habit.”
Aristotle, 384-322 BC
8