The family of a woman who died as a result of neglect and gross failures at a Birmingham hospital are calling for an external investigation.
Rosemary McFarlane died at Heartlands Hospital after she was wrongly given ten times the normal dose of a solution in a routine procedure.
The 64-year-old, of Kingshurst Way, Kingshurst, was administered toxic levels of phosphate buffer saline during a bronchoscopy in August 2008, where an instrument is passed through the mouth or nose into the lungs and fluid is squirted into a small part of the lung for examination, in order to find out how her condition was progressing.
Her death follows a similar incident at the same hospital a year earlier when, in July 2007, two chemotherapy patients suffered fatal overdoses, receiving medication five times its normal strength.
At the inquest into Mrs McFarlane’s death, Birmingham and Solihull Coroner Aidan Cotter, said: “Failures by the pharmacy team as a group and the doctor who conducted the procedure are gross failures and they have sufficient cause of connection to the death.
“The clinical director of pharmacy said there was a series of events which led to the death, a whole series of people were responsible for failures which led to Mrs McFarlane’s death.”
Mr Cotter said while he accepted there were many professional and hardworking staff at the hospital, he added: “We trust you to inject things into us and the thought that some people in the NHS do not check what they are giving to us is appalling.”
The inquest ruled that pharmacy staff and the doctor failed to carry out a series of checks on the newly sourced bottle which contained no information about the concentration.
Mrs McFarlane’s family said that while they were pleased with the coroner’s findings and accepted the profound apologies they had received from the hospital staff, they were considering legal action against Heart of England NHS Foundation Trust.
The inquest was told how the grandmother-of-five, suffering from an underlying condition called pulmonary fibrosis, was admitted to Heartlands Hospital on August 4, 2008.
A pharmacy technician was asked to source alternative supplies of the phosphate buffer saline. When he looked up information, he found there were two lines of the product, one named 1X and the other, 10X.
The product labelled 10X was ordered and without checks from the principal pharmacist, found itself onto the endoscopy ward.
The inquest heard how Dr Adel Mansur and nurse Karen Richardson assumed the new solution was the same strength as other bottles used in bronchoscopies and that the ‘10X’ written on the bottle was part of the long labelling code, then injected Mrs McFarlane in a “pivotal moment”.
They became alarmed after the patient started complaining of “severe burning” in her chest but it took nearly 14 hours to find out if an antidote was available.
Mrs McFarlane died 10 days later from multiple organ failure.
Dr Mark Goldman, chief executive of Heart of England NHS Foundation Trust, who also appeared as a witness at the hearing, said: “We accept the coroner’s verdict and deeply regret this tragic incident and again wish to apologise to Mrs McFarlane’s family. Changes have been made to this procedure to ensure that this will not happen again.”
Mr Cotter previously accused the trust of neglect over two cancer patients death’s in July 2007. Baljit Singh Sunner, aged 36, from Stechford, and Paul Richards, 35, from Sutton Coldfield, died at the same hospital after being given five times the recommended dose of a drug.