Toxic Chemical Error Caused Patient’s Death

Medical Negligence Lawyer Calls For A Full External Investigation

22.12.2009

An inquest has heard that a 64 year old woman suffered an agonising death after a catalogue of errors led to medics at a Birmingham hospital administering a highly caustic, lethal substance into her lungs.

The blunder at Heartlands Hospital happened after a junior pharmacy worker purchased an unlicensed chemical solution ten times stronger than usual, which went unchecked by the hospital’s head pharmacist, a consultant physician and nursing staff.

Birmingham Coroner Aidan Cotter today, Tuesday 22/12/2009, recorded a narrative verdict contributed to by neglect following the death of mother of four, Rosemary McFarlane, from Kingshurst, Birmingham, on 22nd August 2008.

Now a medical negligence lawyer at law firm Irwin Mitchell is calling for a full external investigation to be held and for lessons learned from this incident to be shared with all Trusts across the UK. Mrs McFarlane’s tragic death follows a similar incident at the same hospital a year earlier when, in July 2007, two chemotherapy patients suffered fatal overdoses, after wrongly receiving medication five times its normal strength.

During the two day hearing, the inquest heard how a junior pharmacy worker had been asked to locate alternative medical supplies after the hospital’s usual supplier was unable to provide stocks. The worker used the internet to order a new batch of Phosphate Buffered Saline (PBS) solution, failing to realise that the product was in fact ten times stronger than usual. Concentrated PBS is often used to preserve tissues samples in a pathology lab, but is not licensed for live patient use.

Mrs McFarlane’s lungs suffered irreparable damage when on 12th August 2008 she underwent a routine bronchoscopy to investigate the cause of lung problems and was administered the highly toxic solution for which there is no antidote.

For the next ten days they watched helplessly as Mrs McFarlane slowly succumbed to the chemical which caused her to suffer pneumonia and terminal respiratory distress.

Guy Forster, from Irwin Mitchell Solicitors, who is representing the McFarlane family, explained: “This was a nightmare scenario which had the most tragic of outcomes. Following the initial purchasing error, there were a number of occasions when the mistake could and should have been corrected. However, a series of successive failures by clinicians and nursing staff meant that the mistake went undetected until after the lethal solution was administered.
 
“An internal investigation carried out by the Trust launched identified that the systems that were in place were inadequate and basic checks were not carried out.

“Sadly, there have been previous fatalities at Heartlands Hospital following administration of inappropriate medication and we are concerned that lessons appear not to have been learned by the hospital. An external investigation would not only provide transparency but would ensure other hospitals could learn from the tragic mistakes made by this Trust, which - with its foundation status - is meant to be a shining example of best practice.”

Rosemary McFarlane, known as Marie by her family and friends, leaves behind her husband Ian. The couple had been married for 42 years. A mother of four, she also leaves behind five grandsons.

Speaking on behalf of the family, Mrs McFarlane’s daughter, Annemarie Tranter, said: “Whilst the inquest has provided us with many of the answers surrounding Mum’s death, the family remain angry that she was let down so badly.

“She suffered so much during those last ten days. She was never the sort of person who made a fuss or complained, but the pain was so bad that she was crying with agony and she told us that it felt like her chest was burning. Eventually she was unable to speak but you could tell by looking at her how much pain and distress she was in. It was heartbreaking watching her slowly deteriorate.

 “Whatever happens in the future it’s too late for Mum, but we do hope that today’s inquest will mean lessons have been learnt so that no other family has to suffer as we have."