Chichester hospital makes apology after ‘one-off accident’ led to patient’s death

SORRY St Richard's Hospital in Chichester
SORRY St Richard's Hospital in Chichester
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A HOSPITAL has apologised for a ‘terrible, one-off accident’ which resulted in the death of a pensioner.

An inquest found that Joan Dixon died at St Richard’s Hospital in Chichester 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 says it has introduced a number of measures to ensure such an accident never happens again.

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 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. Nothing comparable had happened before, or has happened in the two years since.’

At the inquest, 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.

‘The 2.5 milligrams of digoxin administered to Mrs Dixon was 10 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, of Findon, near Worthing, 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, 77, appeared ‘dishevelled and confused’ when she visited her the weekend before her death.

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

He said when he returned to work he ensured 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 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.’