Drugs blunder led to hospital death

Kate Newton
A medication bungle at Hawke's Bay Hospital caused the brain haemorrhage that led to a retired farmer's death.
The man was admitted to Hawke's Bay Hospital on January 3 after three weeks of chest pain.
He was diagnosed with unstable angina and administered the drug Enoxaparin.
Half an hour later he was diagnosed with acute lateral myocardial infarction (a heart attack) and was given Heparin intravenously.
Shortly after he complained of bleeding gums and that night a CT scan of his head showed a likely bleed.
He died at 3am the next day and in a statement Dr Andrew Burns said: "I have no clinical doubt that the likely cause of death was a large intracerebral haemorrhage".
A review by cardiologist Keith Dyson said there had been a lack of communication between staff and a delay in seeking advice from the medical registrar.
Heparin should not be administered until 12 hours after the last dose of Enoxaparin.
Hawke's Bay District Health Board's acting chief executive Win Bennett said the board expressed its deepest sympathy to the man's family and had undertaken an extensive review to improve its systems.
"Recommendations from the review had been implemented and continued to be closely monitored," he said. Those included amending the treatment protocol to identify appropriate medication for the patient if their condition and treatment changed, Dr Bennett said
Ongoing education for emergency staff regarding treatment protocols for heart attacks had been implemented and there had been an emphasis on improving communication between emergency department and coronary care staff.
Dr Bennett said it was important to emphasise the coroner's report identified areas that could be improved, but did not apportion blame to any clinical staff member.
"The purpose of investigating such events is to improve patient safety by understanding how these incidents occur and trying to prevent them from happening again," he said.
Hastings coroner Chris Devonport did not hold an inquest because he believed it would not elicit any further information.