bonnie-hughes

My mother was in the High Dependency Unit at Good Hope Hospital, Sutton Coldfield suffering from a urinary infection and pneumonia. She was on intravenous potassium chloride as well as other drugs and after 5 days she was improving, that’s when the most horrific incident happened to her and my family. My little sister had recently given birth to her first baby which my Mum was over the moon about.

My Mum 2007 Singapore

At 6.00 am on Mothers Day 2010 she was sitting up in bed, at 6.15 am a nurse followed the protocol for Intravenous Potassium Chloride signing the Controlled Drugs Record book. She then administered the dose, but unfortunately, she failed to get another nurse to do the final “double” check and she  pressed the administration rate too many times. She set the machine at 100 mmols per hour instead of 10 mmols. From that moment, my Mum who was 5 feet tall and about 6 and a half stone had potassium chloride (a death row drug) pumping into her at 10 times the hourly rate. She then left the room.

After 10 minutes (6.25 am) the nurse returned and noticed that my Mums heart rate and oxygen levels had altered, at that point she did not think to also check the potassium chloride drug supply. Instead she gave my Mum oxygen and called a second nurse (the one who should have done the 2nd check) whilst she went to fetch a Doctor. Another nurse also came in and neither of them noticed the Potassium rate (bright red LED numbers) set at the wrong rate.

The Doctor and crash team arrived at 6.35 am, they too did not notice the administration rate. A blood test showed high levels of Potassium, again they didn’t think to check the infusion. It continued to pump in at 10 times the rate until my Mum suffered a Cardiac Arrest. By now my Mum had had 40 mmols of Potassium (a fatal dose, given as the final drug on death row to stop the hearts of grown men).

Everything they did from 6.40 am to 7.02 am was futile and my Mum was pronounced dead.

The hospital said there had been an “mistake” whilst administering the potassium, they didn’t know if the pump was faulty and that the death would be reported to the Coroner. A post mortem took place and the Coroner opened and adjourned the case.

The hospital called the family in and explained what had happened, that the nurse had been suspended and that they would carry out an internal “Serious Untoward Investigation”. The police were also involved but decided that there were no criminal charges to answer.

On April 1st 2010 the funeral took place and the day after the local paper ran an article the Good Hope Hospital had had a second warning from the Care Quality Commission (CQC) for unecessary deaths due to drug overdoses.

My Mum did not have a will so I had to apply for probate, her estate was not complicated so I dealt with the procedure without the need of a Solicitor. It was dealt with quite quickly and I was then able to open an Executors Account to enable me to pay creditors and put my Mums house up for sale etc.

At the same time I wrote to the NHS for a copy of her medical records and the Hospitals protocol for Potassium Chloride which were provided for a small fee. I needed to know what had happened.

I also contacted AVMA who have provided a Barrister to attend the inquest at no cost.

I researched on the internet and was horrified to discover that these sort of incidents are happening all the time, it is then I joined “Cure the NHS, Stafford” and Justice4Stephen.com and along with other families who had suffered at Heart of England Trust formed Cure The NHS – Heart of England. I want the NHS to admit what they did, apologise and learn from it, something that they are not doing, and prevent it happening to other families.

I wrote to the CQC to advise them of my Mothers ordeal and also wrote to the Nursing and Midwifery Council to consider if the nurses were fit to continue nursing.I also contacted the Prime Minister and local MP and got the usual bland replies.

The hospital notified me that the investigation had been completed so I requested a copy prior to the meeting which was in September 2010. The investigation which involves a root cause analysis was not fit for purpose. They totally failed to identify what the root cause was, other than to say it was human error that the nurse programmed the pump incorrectly. No mention of the 3 nurses and 2 Doctors and crash team that failed in their duty of care to identify what was causing my Mum to deteriorate, an overdose of Potassium Chloride. They also failed to mention that the second mandatory checks had not been followed.

I challenged the report and notified the Coroner of my concerns (this report goes to him to consider when reaching his verdict). The programming error could be classed an human error, but what happened afterwards was negligence. Had they checked the Potassium Chloride as per the protocol, or even checked it whilst trying to save her life, she may not have died. The intravenous pumps are being upgraded to pumps where a programming error is less likely and the protocol is being re-highlighted to staff. But there is no mention of implementing “common sense” mandatory checks when a patient deteriorates.