Hospital doctor admits fatal error

Marie Marsh

Cancer sufferer Marie Marsh knew she had little time left so she set herself small goals, such as spending Christmas with her family.

But instead of making the fruit salad as planned on Christmas Day 2003, Mrs Marsh died after a young doctor prescribed a morphine dose 10 times higher than she should have received.

The doctor's name was suppressed at an inquest held yesterday into the 83-year-old's death.

She is now working overseas, but in a statement read to the coroner's court, the doctor admitted her mistake and said she was "profoundly sorry for my error".

A lawyer acting for the doctor said she suffered "continuing anguish" but sought name suppression because the incident had the prospect of "blighting her medical career".

The first-year house surgeon started work at North Shore Hospital five weeks before Mrs Marsh was transferred from a hospice on December 22 with a suspected bowel obstruction.

Medical notes from the hospice stated that Mrs Marsh had been prescribed 20mg of morphine, administered by a Graseby pump which dispenses the drug over 24 hours.

However, the doctor misread the hospice notes and prescribed 200mg of morphine on Mrs Marsh's chart.

Nurse Catherine Holdaway said she commented on the high dose to another nurse, Vivienne Bennett, when recharging the pump with medication on December 23.

Ms Holdaway said she did not have much experience with the pumps and, calculating the morphine dosage over 24 hours, she did not think it was excessive considering the patient's condition.

Mrs Marsh had cancer of the bowel, and the disease had spread to her liver, lungs and bones. She was also diabetic.

Ms Bennett also told the inquest she thought the morphine dose of 200mg was large but not unnecessary given Mrs Marsh's cancer.

Jenny Rogers said despite her mother's illness, she remained positive and proud of her independence.

"She enjoyed outings and keeping up her appearances," Mrs Rogers said.

When she last saw her mother conscious at North Shore Hospital, Mrs Marsh was "bright as a button" and talking about cutting up fruit for the Christmas fruit salad.

"She told me she wasn't ready to go yet.

"She wanted to go to her granddaughter's wedding in February."

Mrs Rogers was contacted early on December 24 with the news that her mother had lapsed into a coma.

The family was "shell-shocked ... after seeing her so well earlier", Mrs Rogers said.

The morphine error was picked up by palliative care specialist Dr Linda Huggins when she visited Mrs Marsh later that day.

Doctors tried unsuccessfully to reverse the effects of the morphine. Mrs Marsh died at 3.30am on Christmas Day.

Hospital management was questioned about the delay in meeting her family to discuss the error.

A meeting was not held until five weeks after the death, and a follow-up letter sent almost a month after that.

Coroner Murray Jamieson asked Rachel Haggerty, Waitemata DHB general manager of adult health services: "What do you think the next-of-kin of patients who come to grief in your hospital think, when week after week goes by without anyone appearing to communicate ... with them?"

Ms Haggerty said things were handled differently since the death of Mrs Marsh.

The hospital reviewed procedures and introduced new practices.

Dr Jamieson reserved his findings.