Thursday, November 08, 2007

Incompetent NHS hospital: British family demands transplant death inquiry

Grieving relatives of a woman who died in the hospital at the centre of an investigation into the high number of heart transplant patient deaths have expressed concerns about her treatment. Carol Smith, 50, is one of seven people who has died at the Papworth Hospital this year within 30 days of being given new hearts. Transplants at the hospital near Cambridge have been suspended while a review is launched into the deaths to look for common factors.

Last night, her family demanded a full inquiry into her death on May 14 and said they were considering taking legal action. They believe she was given two damaged hearts, that some of her treatment was rushed and that air was allowed to get into critical equipment. It has emerged that the Papworth was also criticised just months ago over the high number of deaths among lung transplant patients.

Mother of four Mrs Smith, who also had four grandchildren, suffered from a condition caused by an enlarged heart and underwent her first transplant on March 8. A problem developed with fluid on her new heart and surgeons conducted a second transplant on May 12. She never regained consciousness and died two days later. Her daughter Rachel Russell, a student nurse, told The Daily Telegraph: "We have still got unanswered questions and Papworth hasn't answered anything. I think the second transplant was rushed. We would consider legal action because we want to know what happened."

The cause of her death was given as cardiac failure at an inquest held last week. David Morris, the South and West Cambridgeshire coroner, delivered a verdict that Mrs Smith "was already in a life threatening situation when a re-transplanted heart failed to respond spontaneously".

Her husband Gerry, 51, said: "The hospital made it seem over-simple and we felt let down." Mr Smith, from Canvey Island, Essex, said he was shocked to hear about the other deaths at Papworth. It also emerged that an external review of lung transplants at Papworth found "a significant problem" with airway complications. Six out of 28 patients died as a result of airway complications - a mortality rate of 28 per cent - between April 2005 and March 2006 with another two deaths in the following months.

Coroner David Morris raised concerns with the hospital in a letter seen by The Daily Telegraph, after the deaths of three patients within six months following lung transplants with similar airway complications. A second letter, signed only "A very concerned patient advocate", alleged that there was a "very serious problem that has been happening for quite some time in Papworth Hospital".

The results of the inquiry by the Healthcare Commission into the heart transplant deaths will be sent to the Government by the end of next week. The Papworth said: "Heart transplants are inherently high risk, complex procedures performed on a relatively small number of patients and the number of operations likely to be affected is therefore small." Simon Roberts, the head of business development and marketing at Papworth hospital, said: "At this stage we are not prepared to comment on specific stories. A review is now underway and we need to allow this process to take place."


Surge in medicine errors in major South Australian public hospital

The direction of change is almost invariably for the worse in Australia's public hospitals

HUNDREDS of medication errors have been recorded at the Royal Adelaide Hospital in the past year, hospital documents reveal. In a situation the state's peak medical body yesterday described as "devastating", it can be revealed 728 medication-related mistakes by doctors and nurses at Royal Adelaide Hospital were reported last financial year compared with 611 in 2005-06. Details of the 19 per cent increase in errors is in RAH safety and quality unit documents, obtained by The Advertiser under Freedom of Information laws.

The Patient Incidents - Medication Related reports show the most common errors are omissions, prescribing problems and overdoses. In 46 cases last financial year, the wrong medication was given and in 11 cases medication given to the wrong patients. During the first six months of this year, seven patients suffered "major permanent loss of function or permanent lessening of bodily function" as a result.

Central Northern Adelaide Health Service acute services executive director Kaye Challinger said there were no patient deaths recorded because of medication errors during the past two financial years. She said, in a written statement, the RAH regarded the incidents as "serious" and a "range of initiatives" had been put in place, including a new medication chart and pharmaceutical reforms. Incident reports are phoned through to a contact centre via a 1800 number.

But doctors, nurses and the State Opposition fear most incidents are going unreported. Australian Medical Association state president Dr Peter Ford said there was a lot of pressure, with hospitals running at more than 95 per cent occupancy. "This really is a scenario for mistakes to occur," he said. "It is a devastating finding."

Australian Nursing Federation state secretary Lee Thomas said the errors "reflected a workforce under pressure". Opposition Leader Martin Hamilton-Smith said the figures were "very alarming". "The statistics for all hospitals should now be made publicly available," he said. But Health Minister John Hill said medication errors affected just 0.37 per cent of the total number of patients treated at the hospital in 2006-07.


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