Care Error Highlights Serious Failure In System

Tue, 18 Nov 2014

A Worcestershire hospital has put in place new systems and procedures following the death of a cancer patient who accidentally received an extra dose of chemotherapy.

An inquest into the death of 76-year-old retired metal worker Derek Marks heard that a clerical error saw him receive seven rather than six doses of chemo at Worcestershire Royal Hospital, where he was being treated for advanced colon cancer.

Mr Marks’ widow was represented at the inquest by Birmingham barrister Richard Grimshaw of No5 Chambers.

Recording a narrative verdict, coroner Geraint Williams said the fact that no-one caring for Mr Marks spotted the error amounted to ‘a serious failure in the system’ but added that he was satisfied Worcestershire Acute hospitals NHS Trust had since put appropriate measure in place to avoid a repeat of the incident.

The inquest heard that Mr Marks attended the hospital on November 30, was diagnosed with a chest infection and prescribed antibiotics and oxygen.

He was discharged on December 2 but returned two days later feeling unwell.

It was discovered that Mr Marks had suffered a cytotoxic injury, serious damage to his lungs as a result of chemotherapy,  and on December 10, three days before he died, he was treated with steroids – a course of action not initially considered effective.

The inquest heard that although there was ‘no doubt’ that the overdose of chemo caused the damage to Mr Marks’ lungs, it was considered that the damage was caused equally by each of the seven doses, rather than the final dose given in error.

Following the inquest, Chris Tidman, deputy chief executive of Worcestershire Acute Hospitals NHS Trust, said: “We are sorry for the failing in Mr Marks’ care and offer our deepest condolences to his family.

“We have carried out a detailed investigation and have subsequently put in place new systems and procedures to ensure that  a similar error does not reoccur.”

Click here to view Richard Grimshaw's profile.

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