Catherine took two painkillers for her bad back and just hours later she was dead – because her GP had prescribed TEN TIMES the correct dose
00:57 GMT, 14 May 2012
When Catherine Rodger swallowed the usual two painkillers for her bad back, it was just part of her bedtime routine.
As a lively and active 75-year-old grandmother of ten, she had never allowed her aches and pains to stop her helping her family with childcare.
But that November evening was tragically different. Thanks to her GP’s negligence, those two tablets would prove to be a death sentence.
Overdose: Catherine Rodger, seen her with her granddaughter Erin, was given a lethal overdose of morphine
Catherine’s daughter Rena Brady, 45, realised something was badly wrong the next morning, when she popped in to see her mother on her way to work.
‘I was panicked to see how terrible she looked,’ she remembers. ‘I could tell by her eyes there was something wrong. She looked like a drug addict, with huge, dilated pupils.
‘I wasn’t used to seeing her unwell. Mum was healthy, young for her age and still lived quite independently. She told me she’d been up all night and was still being sick.’
Rena asked her mother what medication she had been taking. She looked at the box, but a label was covering the dose.
As Catherine deteriorated, Rena phoned the GP. ‘While I was explaining what was wrong, Mum’s eyes just shut,’ she says. ‘I screamed at him to get someone over, hung up and called an ambulance, too.
‘It all happened so quickly. The paramedics arrived and tried to give her mouth-to-mouth.’
But it was too late. ‘There was nothing that could have been done, a lethal dose of morphine was already in her system,’ says Rena.
It transpired that Catherine had been prescribed pills ten times the correct strength by her GP, Dr Salahuddin Malik. Instead of 10mg morphine tablets, Dr Malik had handwritten a prescription for 100mg tablets.
Labelling: Thousands of elderly people like Catherine Rodger fall foul to prescription errors often as a result of the mis-labelling of drugs
Two of those were sufficient to cause her heart to fail.
She had become one of thousands of elderly victims of a prescribing error, as outlined earlier this month in a shocking new report prepared for the doctors’ regulator, the General Medical Council (GMC).
The research found that as many as one in 20 of all prescriptions contained a mistake that ranged from minor to serious.
Patients aged 75 or older were twice as likely to suffer a GP prescription mistake.
Catherine, from Dundee, died in 2005, but it took four years and a private lawsuit for Rena and her three brothers to win justice.
‘We went to court because the authorities decided not to prosecute either Dr Malik or Andrew Nixon — the pharmacist who dispensed the tablets. Nor would they grant us a fatal accident inquiry,’ says Rena, who works as a development agency co-ordinator.
‘We were told it wasn’t in the public interest to have an inquiry, but we wanted to warn people to check prescriptions. What could be more in the public interest than that’
Rena learned in court that 100mg pills are normally used only in palliative care, as single tablets, to ease the agony of people dying of cancer.
Dundee: Mrs Rodger was prescribed the drugs by her local GP in the Scottish city of Dundee
No one should be given double the dose. ‘Apparently, it should have killed her in two hours. It was amazing she survived until morning,’ she says.
‘The whole family was devastated, and so angry. All we got from the doctor was he had written so many prescriptions that day that he had made an error. But it should never have happened. My mother was still healthy — it was not her time.’
The family finally won damages after suing Dr Malik and the dispensing chemist. Dr Malik also received a warning from the GMC, which stated: ‘In future he must pay particular attention to accuracy in prescribing.’
A cardiologist called by the family said that without the morphine overdose which triggered Catherine’s fatal heart attack she would probably have lived another six years.
Such a terrible and premature end to one older person’s life is tragedy enough. But the GMC report makes plain that many more pensioners are in danger from such blunders.
The research examined 6,000 prescriptions by GPs in 15 practices over a year. Four in ten of the over-75s who were taking medicines had been given a prescription with an error.
This is partly due to the fact that older people are often on several drugs, said the study.
The report estimated that one in every 550 GP prescriptions involves a severe mistake.
Almost all serious errors related to one drug, warfarin. It is prescribed to thin the blood of those at risk of blood clots — mostly vulnerable older people — but can cause life-threatening internal bleeding and circulation problems.
Staff at Wythenshawe Hospital in Greater Manchester apologised to the family of Edith Reid, 81 after she died of heart failure when she was given warfarin
The dangers of mis-dosing warfarin were highlighted in the case of Edith Reid, 81, a grandmother who died after being taken to hospital with a persistent nosebleed.
Mrs Reid had been taking the drug since a heart operation 20 years previously. When she was admitted to Wythenshawe Hospital near her home in Urmston, Greater Manchester, in August 2008, she was taken off the drug to reduce the nosebleed.
As she recovered, doctors began re-introducing it, but staffing was low and mistakes were made in blood-clotting tests undertaken to ensure the blood does not thin excessively.
Mrs Reid died of heart failure just over a week after being admitted to hospital. An inquest was told it was impossible to identify who was at fault because new staff had been using a colleague’s computer log-in.
The hospital apologised to her family and said steps had been taken to improve how staff prescribe and administer drugs. Her husband Eric, 80, said: ‘They gave her warfarin like sweets. If it was me who’d done this, I’d be in prison.’
In the new GMC study, warfarin was found to be one of the top two drugs associated with monitoring errors. The other was the statin drug Simvastatin, given to lower cholesterol levels.
Both drugs are commonly prescribed to
older people and are known to interact dangerously with other medicines —
particularly with each other.
High standards: Dr Clare Gerada, the Royal College of General Practitioners chair of council has hit back at claims saying that 'prescribing standards are, in the main, extremely high'
Widely-used antibiotics given for urinary infections, also common among older people, can interfere with warfarin’s potency.
Warfarin should be monitored particularly closely by GPs because its effects can be altered by things as simple as everyday diet.
Prescription guidelines say GPs should never assume patients can stay on the same dose indefinitely. Good clinics often ensure that even stable patients get tested once a month.
However, the GMC study found instances where patients on warfarin had not been tested for two years.
Another common prescribing error found by the report involved GPs failing to give stomach-protecting drugs to older people on non-steroidal anti-inflammatory painkillers, which can cause gastric bleeding when taken over the long term.
The report says: ‘Overall, these findings suggest that greater attention needs to be paid to the elderly to prevent (or detect and correct) errors.’
Indeed, the extent of such prescribing problems may be even worse in care homes for the elderly, according to a report published in 2009 in the journal Quality And Safety In Health Care.
It found that almost four in ten care home residents had suffered one or more prescribing error.
If the GMC report’s figures were extrapolated across the whole NHS, where GPs sign off more than 900 million prescriptions a year, 45 million would contain errors and 1.8 million of those would be severe.
The man who led the GMC study, Professor Tony Avery, admits: ‘Given the paucity of research into the prevalence and nature of prescribing and monitoring errors in general practice, it is difficult to compare the findings from our study with other literature.’
In fact, though, an earlier study by Avery, a professor of primary healthcare at Nottingham University, found that prescription errors by GPs may cause around one in every 20 hospital admissions.
His research for the Department of Health in 2006 on nearly 4,100 hospital admissions showed that almost five per cent were caused by a ‘preventable drug-related morbidity’.
Furthermore, in December 2008, the Healthcare Commission (the clinical standards body now replaced by the Care Quality Commission) quoted a research review showing that GPs may be committing up to 600 errors a day, mainly in diagnosis and treatment. Up to 120 of these errors were thought to cause harm.
Nevertheless, doctors’ organisations have played down the problem. Dr Clare Gerada, the Royal College of General Practitioners’ chair of council, said: ‘Prescribing standards are, in the main, extremely high.
‘Any error in GP prescribing is regrettable and is taken very seriously by GPs and their teams. The report helpfully identifies some areas where improvements can be made.’
The GMC gave the results of its new study a positive spin, headlining its press release: ‘GP prescribing — a good standard but improvement possible.’
The former Healthcare Commissioner Sir Ian Kennedy lamented that there is a black hole in information available on mistakes in GPs surgeries
It added: ‘Few prescriptions were associated with significant risks to patients but it’s important that we do everything we can to avoid all errors.’
However, experts believe GPs remain in denial about the extent of their prescribing errors.
Peter Walsh, chief executive of the charity Action Against Medical Accidents, says GPs ‘massively under-report’ adverse prescribing incidents.
‘It is partly to do with the defensive culture in medicine, and partly to do with the fact they are independent contractors to the NHS,’ Mr Walsh says.
‘This has meant they have been treated as less directly accountable.’
He explains that, as a result, GPs were not required to report their prescribing mistakes to an anonymous database of ‘adverse incidents’ set up by the NHS, called the National Reporting and Learning System, to help experts track problems and introduce safeguards.
The system remains entirely voluntary for GPs and Mr Walsh says: ‘Of the one million reports of adverse incidents sent by NHS doctors each year, only a tiny fraction are from GPs. They are not playing ball.’
Indeed, the former Healthcare Commissioner Sir Ian Kennedy lamented that there is a ‘black hole’ in information available on mistakes in GPs’ surgeries.
In the commission’s annual records of incidents across the NHS in which patients were put at risk, less than half a per cent were reported by GPs.
This may change next year when it is planned that GPs will be forced to register with the Care Quality Commission and take part in the National Reporting and Learning System.
Meanwhile, GPs are increasingly relying on computer programmes to flag up potential prescription problems. Software often flashes up warnings about drug interactions or unusual dosages. But computers cannot remove human error.
This was highlighted in 2010 when a coroner’s inquest heard how 85-year-old Mary Healy, of Leeds, died after being given someone else’s prescribed drugs for days after she had an operation for a broken hip at Leeds General Infirmary.
Claire Duggan, the pensioner’s daughter, first became worried after she found her mother slumped over her lunch on the hospital ward.
Baroness Young, the first chairwoman of the Care Quality Commission, pledged a Commons Select Committee inquiry into patient safety in 2009 that she would place GP mistakes under the microscope
Mrs Healy had been given drugs, including sedatives, meant for a patient suffering from epilepsy and mental health problems.
Claire reportedly told the coroner’s court that she believed those drugs contributed to Mrs Healy’s death a month after she went into hospital. Police believe the prescription mistake was made after hospital staff called the GP surgery to ask about her medication.
The inquest in Wakefield heard that a computer search was made at the doctor’s surgery. But instead of Mrs Healy’s prescription details, the drug requirements for the patient next on the list were read out.
Mary’s son Martyn Healy, 53, from Northumberland, recalls: ‘My mother ended up on seven different drugs for epilepsy, schizophrenia and all manner of mental health problems. Some of these drugs were in very high doses.
‘The effect this had, as they were all drugs designed to take people “down”, was to turn her into a vegetative state.
‘My younger sister Clare was there when a nurse administered a drug and questioned what it was for. The reply was: “For the epilepsy.”’
This rang alarm bells, but Mrs Healy had been on the drugs for a week by then and in her massively sedated state she developed a chest infection and died two weeks later.
Martyn adds: ‘The coroner delivered a narrative verdict mentioning the drug error. As she died two weeks later it could not be attributed to her death but it certainly affected her tremendously.’
Even when GPs do come under the regulatory authority of the Care Quality Commission, many fear the watchdog will prove toothless in protecting vulnerable older patients.
Baroness Young, its first chairwoman, pledged to a Commons Select Committee inquiry into patient safety in 2009 that she would place GP mistakes under the microscope.
But she resigned after Basildon Hospital in Essex was exposed for having filthy wards and a high death rate, despite being rated ‘good’ by the regulator.
And last February, the watchdog’s chief executive Cynthia Bower quit following a Department of Health report into repeated failures in care home supervision.
The commission has been in no hurry to get to grips with general practitioners. It will only start regulating them in April next year.
‘Their inclusion is part of a staged process,’ says a commission spokesman. ‘We will be inspecting their services, including checking whether their handling of medicines is well-managed.’
For matters to improve, GPs will have to become more open to criticism of their prescribing.
As the GMC study makes clear, until GPs face up to the problem, this scandalous disregard for elderly patients will never end.