NHS critic killed by medical error

So, irony isn’t just for stateside medicine:

Telegraph | News | Patient’s liver ‘saturated’ with iron after hospital confusion over dosage

Patient’s liver ‘saturated’ with iron after hospital confusion over dosage
By Daniel Foggo

A critic of declining standards in the National Health Service died after being given a large overdose of iron by a hospital doctor who did not read the instructions on the drug’s label properly.

Carys Pugh, 63, a former president of a patients’ association in Wales, was taken to casualty at the Royal Glamorgan Hospital after the blunder turned her skin brown and “saturated” her liver with iron.

While she fought for survival in hospital for seven weeks, Mrs Pugh suffered a heart attack and contracted deep vein thrombosis in both legs, a chest infection and then E.coli. Finally, she suffered a second heart attack that killed her.

When her daughter, Hawys Pugh, complained to the hospital authorities about what had gone wrong she was told that the doctor who had carried out the routine infusion for suspected anaemia had found the instructions difficult to decipher and that he had only read half of them.

“They told me that because the text was in two columns instead of one, the doctor just read the section on how much to give, but didn’t bother reading the rest which said over what duration it should be given,” Miss Pugh said.

“Instead, he just put the entire dose into her system in one go. They suggested it was the manufacturer’s fault and said they would be contacting them.

(emphasis added).
Medication errors happen everywhere, it’s human nature. It’s human, but probably not terribly professional, to blame a manufacturer for having not bothered to read the instructions.

cross posted on TheLingualNerve
thanks to reader Jim for the steer


  1. I’m unclear on your point here. Are you amused that a “critic of declining standards” in medical care falls casualty to an egregious medical error? Are you sanguine about such errors– they “happen everywhere” — shrug — “it’s human nature?” Interesting reaction. You’re a doctor, but you don’t give a shit? You dwell on what’s the “professional” way to deal with it? How about implementing stringent systems to prevent such lapses? And if they’re as “unprofessional” as the failure to actually read — and fully understand, or else ask for clarification of — the instructions for administration of a medication, the guy ought to get his ass sued off for malpractice. But, yeah, I know. You think all malpractice suits are manifestations of greed, either on the part of the patients or the lawyers.

  2. I believe, DOW, that instead of reading into my posts, you should endeavor just to read the post. Though I’m not a professional writer like you, my words have meanings. If you’re unclear on my point, just try reading a little more slowly, or aloud.

    “Amused’ is your word, I never used it and it’s not amusing that this person died. I find it ironic, which is the word I used. They are not synonymous. Look it up.

    Most malpractice actions are just greed, and I have direct, close and personal knowledge. I find it interesting that your response is “sue the doc”. Telling.

    This isn’t the first time you’ve written to me, and found slurring my professionalism to be your best insult. Find someone else to write to, and feel free to post your screeds on your own site.

  3. Reading carefully, I think you will find that I did not slur your own professional standards in any way. I did suggest that you’re too easily repeating a point of view that hampers advances in patient safety. Of course errors happen. And no, not all of them are the results of negligence. Mostly, say the experts, they are symptoms of system problems. (This one, as reported, clearly was not; but, as with all these stories, you really need to know more details before you draw hard conclusions. Same goes for malpractice suits and even hot-coffee spills and “Jacuzzi accidents.”) And I too wish there were an alternative to suing doctors when things go wrong. Again, I agree with you that the kneejerk leap to sue a doctor is often simple greed — “wow, Ma’s dead but we just won the lottery!” In fact, most victims (or their survivors) are grieving and looking for some sort of solace, which in this society generally translates to money. And if you’re facing a lifetime of huge expenses and pain, there’s really no mechanism in our medical care system to help you out as your own resources dwindle, or you never had any to start with. Maybe you go on charity care — another unfair burden on physicians’ and hospitals’ ethical mission. I do actually sympathize with those — especially good doctors who’ve been burned — who’re embittered about the malpractice situation… but I think the answer has to be some sort of no-fault or universal insurance system. Meanwhile, evidence suggests that doctors who are pleasant, empathetic and honest with their patients are less likely to get sued when they err than those who are aloof and stonewall. And I wouldn’t be surprised if it isn’t more difficult for an ER doctor (or other in-and-out specialists like surgeons) to have that kind of relationship with a patient. Continuity of care, of course, is an obsolescent concept as things stand. It was that “personal warmth” thing that bothered me about this post and it’s characteriztion of the death with the cold word “ironic.” Yes, I know, ironic gets misused as a kind of synonym for “amusing” or “weird,” and you did not go there directly. But even reading aloud, I couldn’t hear anything other than — at best — clinical dispassion in the account. That’s okay, certainly professional… but still I come away unclear on the take-away message you intend. Which I responded to. Sorry if you don’t like feedback. I’ll oblige you by ceasing to provide it.

  4. Hehe, who’s the one with the feedback problem? I called you on errors in your feedback, which was really your way of trying to make me sound like I thought this death was funny, and that the answer was to sue.

    Your latest response was better thought-out, and sorry you’re bothered by my lack of personal warmth. I see a lot of death, and my comments on those who die (and, we all die) are because there’s something to be learned, or it’s at least unusual.

    I’m a reasonably likable fellow, and most of the nurses I work with tell me I’m easy to work with. All that not getting sued by being nice works for office-based docs, but not for ER docs, in my experience. Lots of us are getting sued, and I’m around my colleagues enough to know which are likeable and which aren’t, and there’s no correllation, in my experience.