Patient death: trust admits failings in nurse medication training
A man living with metastatic bladder cancer received multiple overdoses of morphine from nurses who should have recognised that his prescription was inappropriate and doctor failed to scrutinise prescription, states coroner report, with NHS trust admitting failings in medicines prescribing and administration.
Man died after nurses gave multiple overdoses of morphine and doctor failed to scrutinise prescription, a coroner found. NHS trust admits failings in medicines management
A man living with metastatic bladder cancer died after being given multiple overdoses of morphine by nurses due to a prescription error, a coroner found.
Paolino Amico, 63, was treated for severe pneumonia after being admitted to the emergency department (ED) at Princess Alexandra Hospital in Harlow, Essex, on 9 June 2024.
After he was moved from the ED to a ward, between 10 and 11 June 2024 nurses gave Mr Amico three times as much slow-release morphine sulphate (MST) as he should have had in a 24-hour period.
He received six doses of MST rather than two doses, said coroner Sonia Hayes in a prevention of future deaths report published on 17 November.
Senior nurse recommended that the trust make medicines administration refresher training mandatory
The coroner said multiple nurses were involved in morphine administration and all had completed their original training outside of the UK, but they had undertaken medicines administration training at Princess Alexandra Hospital NHS Trust and should have recognised that the prescription of MST four times a day was not appropriate.
She criticised the trust for not following senior nurses’ recommendation to make medicines administration refresher training mandatory for nurses.
The report states that when the ED nurse caring for Mr Amico could not find the doctor allocated to him to prescribe pain relief, she did not escalate this to the nurse in charge or a senior doctor. Instead she approached a ‘junior and very busy’ foundation year 1 (FY1) doctor and said the morphine frequency needed to be increased.
Nurses did not flag concerns about the possibility of a prescription error
The pair did not sufficiently scrutinise the prescribed medication, which led to the controlled drug being increased from two doses daily to four. The FY1 doctor also did not escalate the matter or review Mr Amico before prescribing it, said Ms Hayes.
His family was incorrectly told medication had not been prescribed. He was then given an MST dose from his own supply, but this was not recorded by the ED nurse.
After his ward transfer, multiple nurses were involved in checking and administering the MST on five occasions between 10 and 11 June. They did not flag concerns about the possibility of a prescription error, or note that Mr Amico had already taken one MST dose that morning despite their medicines training, the coroner said.
Other concerns flagged include:
- Mr Amico not being referred to pain management.
- There being a delay in raising a medical emergency when Mr Amico’s National Early Warning Score (NEWS2) increased to 10.
- His morphine reversal and subsequent pain relief were not managed according to British National Formulary or NHS England guidelines, and he died in hospital on 12 June 2024.
Trust says it recognises missed opportunities to provide safer, more consistent care
The trust has until 12 January to respond to the coroner’s report. Its interim chief nurse Jo Ward said the organisation’s own review had found ‘clear failings’ in medicines prescribing and administration, clinical escalation and communication with his family, describing these as unacceptable.
‘We recognise missed opportunities to provide safer, more consistent care,’ she said.
‘We have acted swiftly to prevent this from happening again. We have strengthened our electronic prescribing system to prevent incorrect morphine dosing, reinforced escalation requirements aligned to NEWS2, strengthened senior clinical oversight, and are introducing mandatory medicines management refresher training for all registered nurses alongside additional safeguards for controlled drugs.’
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