Family Taking Legal Action As Doctor Admits Serious Errors Led To Death

The family of a woman who died after being prescribed a drug four times in four months despite it being recorded on her medical records that she should not be given it, say they are disappointed that they have not yet received an apology from the doctor responsible.

Mother-of-two Carol Gibson, 65, from Palacefields, Runcorn, died in August 2012 as a result of an adverse reaction to the drug nitrofurantoin which was prescribed to help ease symptoms of a urinary tract infection despite her suffering similar issues when prescribed the drug four years earlier.

Her devastated family instructed specialist medical negligence solicitors at Irwin Mitchell in Manchester to investigate her care after she died just a week after the 4th prescription in 4 months. Since then an inquest has heard how alerts on her medical records were ignored and the doctor responsible for her care has recently admitted liability for her death via his legal representatives.

Lawyers at Irwin Mitchell are now working to secure the family a final settlement but the family is disappointed at the lack of an apology and are worried about what they say is a lack of accountability.

At an inquest into her death the coroner highlighted a number of concerns into the care provided by Dr Otiv, from the Castlefields Health Centre in Runcorn, including:

• Dr Otiv ignored a warning alert in the medical records regarding the adverse reaction to nitrofurantoin and prescribed it
• Concerns regarding the inputting of data from hospital letters regarding adverse reactions
• Indications from Dr Otiv that the partners experienced a form or “alert fatigue” – he said “most are trivial, spurious, irrelevant or just wrong”

The Coroner wrote a regulation 28 report to health centre requesting clarification that robust systems were in place for posting alerts and that they correctly identified problems and that medical staff were fully trained and understood the alerts.

Castlefields Health Centre has responded to the letter saying that they had taken significant steps in order to prevent further mistakes such as regular group case reviews, and a change in the procedure for identifying adverse reactions in medical records.

Ayse Ince, a specialist medical negligence lawyer at Irwin Mitchell, representing the family, said: “This is a truly tragic death which could have been prevented had Dr Otiv not ignored warnings on her records about the drugs she was been prescribed.

“It is totally unacceptable and, as the Coroner also suggested, raised serious patient safety questions about whether the alert system was adequate to prevent the same mistakes happening again. It is encouraging to see that the health centre has responded quickly to the coroner and we hope that their new systems will prove to be successful in eliminated any similar issues.

“The family was distraught when they found out what happened and is determined to ensure there are improvements made to the systems so that no one else has to suffer as they have in future.”

Mrs Gibson had a history of severe urinary tract infections with both physical and mental symptoms and in 2007 her GP Dr Otiv took advice from a consultant and prescribed nitrofurantoin. She then suffered serious lung disease because of the drug and in 2008 when this was recognised her prescription was stopped and an alert posted on her records.

However in August 2011 Mrs Gibson again suffered a urinary tract infection and Dr Otiv failed to heed the alert and prescribed her with nitrofurantoin again. She was given a further prescription in April 2012 and on 26th July a nurse also issued a prescription. Finally on 1st August 2012 she was issued another prescription without being examined by medical staff. She died at home just seven days later on 8 August 2012 because of an adverse reaction to the drug.

Mrs Gibson’s daughter Helen Dundon from Runcorn, said: “We still don’t understand how this could happen and are very unhappy as we have heard nothing about how the GMC investigation is going. We have also not received any apology from the doctor or the health centre which raises questions about whether they are truly learning from this.

“It is quite clear from the inquest and the legal admission that very serious mistakes were made in my mother’s treatment but it would appear that no one is going to be held to account.

“It’s incredibly frustrating and doesn’t send out the message to other medical staff that they need to ensure alerts are properly acted upon. If no one is ultimately held to account for such serious errors then it makes us wonder about the desire to see real improvements in future.”

Dr Otiv currently has conditions on his GMC licence which involved letting the GMC know where he is working and that his work must be supervised by another GP.

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