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Patient's death after drug mix up Patient's death after drug mix-up
(4 days later)
A heart patient died after a breakdown in communication at the hospital treating him, an inquest has heard.A heart patient died after a breakdown in communication at the hospital treating him, an inquest has heard.
Paul Smith, of Cardiff, took blood-thinning medication for a month instead of a year and died after a blood clot.Paul Smith, of Cardiff, took blood-thinning medication for a month instead of a year and died after a blood clot.
Coroner Mary Hassell recorded a narrative verdict and said Mr Smith, 46, was given the wrong instructions at University Hospital of Wales, Cardiff.Coroner Mary Hassell recorded a narrative verdict and said Mr Smith, 46, was given the wrong instructions at University Hospital of Wales, Cardiff.
Cardiff and Vale University Health Board said after the hearing it did not comment on individual cases.Cardiff and Vale University Health Board said after the hearing it did not comment on individual cases.
Mr Smith, a father of three, was prescribed the drug clopidogrel but stopped taking the medication after a month as directed on the medication card he was given. Mr Smith, a father of three, was prescribed the drug clopidogrel, but stopped taking the medication after a month as directed on the medication card he was given.
It seems to me there were several points at which information could have been clearly communicated but it was not Mary Hassell, coronerIt seems to me there were several points at which information could have been clearly communicated but it was not Mary Hassell, coroner
Less than four weeks after he stopped taking the drug, he had a blood clot in his heart. He was operated upon but died of complications the following day.Less than four weeks after he stopped taking the drug, he had a blood clot in his heart. He was operated upon but died of complications the following day.
The coroner, who returned a narrative verdict, said: "Mr Smith was given the wrong instructions because of a breakdown in communication between the specialist registrar and the staff nurse.The coroner, who returned a narrative verdict, said: "Mr Smith was given the wrong instructions because of a breakdown in communication between the specialist registrar and the staff nurse.
"The correct message was neither correctly relayed, nor clearly understood.""The correct message was neither correctly relayed, nor clearly understood."
She added: "It seems to me there were several points at which information could have been clearly communicated but it was not.She added: "It seems to me there were several points at which information could have been clearly communicated but it was not.
"It wasn't just about one person speaking to another, but the method of writing it down, whether it was written clearly and whether one part of the notes were completed before another."It wasn't just about one person speaking to another, but the method of writing it down, whether it was written clearly and whether one part of the notes were completed before another.
"All of these factors combined to mean that the person who gave Mr Smith his green medication card thought the blood thinning medication was to be given for a month when in reality it was to be given for a year."All of these factors combined to mean that the person who gave Mr Smith his green medication card thought the blood thinning medication was to be given for a month when in reality it was to be given for a year.
Electronic prescriptionsElectronic prescriptions
"As a consequence of that he didn't receive the protection against blood clots that those treating him had intended and, as a consequence, he suffered a blood clot and a heart attack.""As a consequence of that he didn't receive the protection against blood clots that those treating him had intended and, as a consequence, he suffered a blood clot and a heart attack."
The inquest was told about changes that had been made to procedures at the hospital since Mr Smith's death.The inquest was told about changes that had been made to procedures at the hospital since Mr Smith's death.
These included prescriptions being written out in full - in block capitals, with no abbreviations - before they are given to a nurse to fill out the medication card.These included prescriptions being written out in full - in block capitals, with no abbreviations - before they are given to a nurse to fill out the medication card.
Electronic prescriptions are also being considered.Electronic prescriptions are also being considered.
A review is also under way to get a uniform agreement on the usage of clopidogrel.A review is also under way to get a uniform agreement on the usage of clopidogrel.
Ms Hassell said Mr Smith underwent an emergency procedure on 6 July to suck out the clot, and blood thinning drugs were administered.Ms Hassell said Mr Smith underwent an emergency procedure on 6 July to suck out the clot, and blood thinning drugs were administered.
But fluid built up around his heart as a consequence which made it difficult for the organ to function, Ms Hassell said.But fluid built up around his heart as a consequence which made it difficult for the organ to function, Ms Hassell said.
Punctured liverPunctured liver
A drain was inserted to remove the fluid, but his liver was punctured during that process. This was a recognised complication of that procedure, the inquest heard.A drain was inserted to remove the fluid, but his liver was punctured during that process. This was a recognised complication of that procedure, the inquest heard.
Mr Smith's consultant left the hospital at about 6.30pm and there was no documented review of his condition until just before midnight, by which time he was very poorly, the inquest heard. He died four hours later.Mr Smith's consultant left the hospital at about 6.30pm and there was no documented review of his condition until just before midnight, by which time he was very poorly, the inquest heard. He died four hours later.
A post-mortem examination showed that more than three litres of blood had flooded into Mr Smith's stomach from his punctured liver, and this had caused a heart attack.A post-mortem examination showed that more than three litres of blood had flooded into Mr Smith's stomach from his punctured liver, and this had caused a heart attack.
In a statement read to the court, Mr Smith's widow Claire said: "I feel I have lost my loving husband unnecessarily."In a statement read to the court, Mr Smith's widow Claire said: "I feel I have lost my loving husband unnecessarily."
She said the carpenter was a devoted father to their three children.She said the carpenter was a devoted father to their three children.
A spokeswoman for the Cardiff and Vale University Health Board said it would need to review the narrative verdict before making any other comment.A spokeswoman for the Cardiff and Vale University Health Board said it would need to review the narrative verdict before making any other comment.