Verdict Of The Coroner's Inquest - Essay Example

? PURPOSE Pursuant to the requirement to investigate suspicious, or negligent causes of death as implied in article 2 of the European convention on Human Rights an inquest is necessary. (Jordan versus UK, 2001) The causative factors leading to the death of the patient, as well as conditions contributing to his demise will be investigated, in addition to recommendations to prevent such fatalities in the future. RECOMMENDATION the greater oversight on the channels of communication between physicians prescribing medication and pharmacists who calculate proper dosages. To the extent that it is economically feasible, a quality control expert could limit the number of deaths likely to occur through miscommunication between medical professionals. REASONS FOR RECOMMENDATION There is every indication that the drugs themselves were the correct ones for this patient, the amounts administered were simply many times greater than a normal daily dose. Nor is there any indication that the pharmaceuticals themselves were in any way tainted or compromised. It was not a failure of medical science, but simply a question of administration and bureaucracy. BACKGROUND On January 1st, 2011 the patient 'J' was pronounced dead. Pursuant to the requirements of a formal Inquest into the death of the subject, hereafter referred to as J. This outpatient of the Newland Hospital medical system was suffering from nodular sclerosing Hodgkin's lyphoma, which was a contributing factor in J's death. This pathology was not the cause of mortality. A drug overdose was the actual cause. While the prescription was accurate, a miscommunication in the levels of dosage resulted in excessive toxicity to the patient. An apparatus was already in place to confirm the details and precise quantity of the drugs in question, but proper procedure was not followed to confirm the prescription. This inquest will be conducted pursuant to Coroner? Rules 1984 in England and Wales, and in Northern Ireland under the Coroners (Practice and Procedure) Rules (NI) 1963 as amended. In this case the death was not intentional, but negligence was a contributing factor, which is different from actual neglect. Neglect in this case being defined as "a gross failure to provide basic attention to someone in a dependent position." (Matthews, 2010) The law does draw a distinction between neglect and the negligence While essentially accidental, a failure by caregivers was the actual causative agent. The medical staff failed in their essential duties towards this patient, but health care was provided although the proper precautions were not taken to ensure that the prescribed treatment was administered correctly. It is noteworthy that the specialist pharmacist stated that no single person w as completely responsible for the death, in the capacity of sole culprit. ?he system was in place, not wholly effective.There were mistakes made by several parties. Yet it is clear that the mistaken dosage was clearly an error, per the professional diagnosis by Dr. R, where he described the dispensation of the medication as 'glaringly wrong', and a 'huge aberration.' Furthermore, investigations of medical findings pertaining to nodular sclerosing Hodgkin's disease will reveal that the condition is not invariably fatal. (van Spronsen et al., 2000) The inevitability of J's death is not to be taken for granted with absolute certainty. While a doctor had predicted the patient's present status to most likely result in mortality, the death of this individual was not unavoidable from this condition, nor should the consequences of his demise be viewed as less severe, on account of J's age or health status. Even should the physician's estimate of 27 months have been accurate, negligence is still apparent, and the patient was not entirely beyond hope. And while the Dr. has noted that J's condition was terminal, with a 27 month probable lifespan based on medical precedent for others suffering from nodular sclerosing Hodgkin's disease, the five-year survival rate ranges from 90 to 60%, depending upon the stage of the lymphoma, from 1 to 4. The diagnosis of Hodgkin's disease is achieved as a result of lymph node biopsy. The disease variant located within J, nodular sclerosing is the most common variant, while at the same time the type of the disease having the worst prognosis. (Mendenall, 1999; Potter, 1999) the postmortem examination of the patient was conducted by Prof. B, who concluded that the overdose of chemotherapy drugs was the triggering agent without which the deceased would still be alive. The standard principle behind chemotherapy pharmaceuticals is a measured dosage intended to kill rapidly growing cells. Under ideal conditions, this will spare major organ systems from damage while targeting cancerous tissues which by definition are growing uncontrollably. The overdose given to patient J was sufficient to damage both the cancerous lymphoma as well as normal cells, leading to organ failure. Based upon the testimony of the medical and pharmacy staff, the types of errors that were committed in this instance do not give evidence of being in any way specific to this case. The age and health of this individual, specifically his particular anthology did in no way cause or contribute to the medical errors that led to a fatal overdose. This particular case should not have proven unusually challenging for the medical staff, nor did it involve experimental treatments outside of their normal area of expertise. If the pharmacy and outpatient procedures of the Newland hospital pertaining to the treatment of patients at Leafy Meadows results in the misinterpretation of handwritten prescriptions from the physician overseeing that treatment, then this is a problem that might occur again, and in the case of any other patient. Any prescription could have been mishandled based upon the failure of procedure within this institution, with similar results for any other patient of any age, sex, or pathology regardless of the prognosis. It has been stated during the evidence for this hearing that a confirmation apparatus was in place for the proper communication and translation of prescriptions into the appropriate dosages of chemotherapy pharmaceuticals. The staff of Newland hospital were aware of the probable risk factors from miscommunication of prescriptions, yet they failed to deliver the appropriate care to the patient when the reasonably expected to do so, not because of inability; but rather a failure to perform as they knew they should, in the manner in which they had been trained. The failure in this case was one of simple negligence. Should the damages in this case represent mere replaceable commodities, then this lapse could be dismissed as the inevitable consequence of human error. But for matters of life and death a higher standard of care and oversight should be mandated whenever, and wherever possible and economically feasible. Furthermore is the consideration that blame for the death does not appear to be localized to a single act of negligence committed by a specific individual. The entire staff of the pharmacy shares some culpability for the death. The primary physician has assuredly written prescriptions before; prescriptions which in many cases were correctly interpreted by the head pharmacist and the ancillary professionals responsible for the calculation, interpretation, and preparation of the dosages; in addition to the administration of said doses once prepared. Should ambiguity exist, there were many individuals within the pharmacy that had opportunities to question the exact meaning of the '1/7', or the 3/7 written dosage requirements of the Lomustine and Etoposide chemotherapy pharmaceuticals. These drugs were prescribed as palliative therapy for Hodgkin's disease. Pursuant to the question of "how the deceased came by his death," relevant systemic issues may be considered in order to provide a more thorough recommendation on ways to prevent similar fatalities in the future. (As permitted based upon Amin versus Secretary of State for the home Department, 2001) Potential recommendations for the prevention of such negligent deaths in the future are as follows: The implementation of a prescription drug quality control checklist. While an apparatus was already in place that should have been able to prevent this sort of error from occurring the best option for the prevention of similar occurrences would be a specialist to examine documentation pertaining to prescriptions written by the physician and the administration of drugs resulting from the pharmacist. With the generation of a checklist with redundant verifications of the exact nature of the pharmaceuticals, and their translation into a dosage schedule a form of oversight would be created that could prevent such deaths in the future. Physicians themselves have among the most demanding and complex jobs in existence, today and the pharmacists must oversee the treatment of a never ending stream of patients. It is natural that medical professionals will be preoccupied with problem solving and the management of their respective offices. It could prove beneficial to include another professional, or company that examines documentation for completion, legal compliance and adherence to safety standards. The question becomes whether adding another level of bureaucratic control will be cost-effective when weighed against liability concerns. The necessity of additional controls is underscored not by the unusual behavior or demands placed upon the principal pharmacist L, but because there were no unusual demands. The schedule of the pharmacist at the time of the incident did not impose any non-standard difficulties or time constraints. There is no apparent evidence of procedures or processes that exceeded the expertise of the principal pharmacist or those serving under him. And all members of the pharmacy staff would have understood that compounding over a week's worth of chemotherapy treatments into a single day's dosage yielded the potential for fatality. While no single individual was entirely to blame, the principal pharmacist has the final authority over the qualitative and quantitative characteristics of treatments formulated within his pharmacy. A simpler alternative to the acquisition of a new employee would also be the replacement of the principal pharmacist. A judgment must be made however, as to whether or not a replacement would be likely to make a similar error, and as to whether the present pharmacist has particular value to the healthcare system that would warrant retention. The principal pharmacist, L did perform a professional check based upon the available testimony, the results of which should have confirmed the proper dosage, and revealed the inappropriately high amounts that the patient was set to receive. A chief pharmacist with more specific chemotherapy knowledge might not have made such an error, but the resources and expertise were still present to allow L to identify the mistake. No single medical professional could be expected to hold complete expertise on every possible treatment, but it is suspicious and hopefully rare for a physician or pharmacist to experience a lapse in judgment of this severity. Although the error in this case was compounded primarily by the pharmacy. There were many instances within the chain of events leading from initial prescription to the mistaken administration or other professionals could have caught the error, but it should be within the purview of the chief pharmacist to prevent the errors of others, not to compound them with fatal results. SUMMARY The essential findings of the inquest are condensed below: The patient, J received more than a week's worth of chemotherapy treatments within one day. The handwriting of the physician generating the prescription was misinterpreted. An apparatus was in place to confirm the prescription. The principal pharmacist had an opportunity to verify the correct dosage, but let the error stand. The patient, J would not have died after that time had he received the correct dosage. The range of possible verdicts under circumstances similar to these could initially be interpreted as the result of foul play. There is no present evidence that any staff members involved had anything to gain by the death of J. Nor is there any indication that the miscalculation in dosage was deliberate. The cause of death seems essentially accidental, but the chain of events cannot be explained simply as an 'act of God', or the result of any disaster due to the human involvement leading to the death of the patient. This eliminates the possibility of death by natural causes, despite the presence of Hodgkin's lymphoma. An accidental mis-adventure could imply an error on the part of the deceased with no additional human involvement, but this is not the case. As the patient was dependent upon the care of the leafy Meadows rest home under the medical authority of the Newland Hospital, intentional drug abuse is not a possibility; there being no apparent recreational or financial incentive for the individual patient in the deliberate abuse of the chemotherapy drugs described herein. The retired patient could not have presently been engaged in a career that would have led to a death by occupational disease, given the manner of his death. No motivation or evidence for suicide, or any self-defense necessity that might provoke a 'lawful killing' can be attributed to this case. (Per the verdict of Portsmouth Coroner ex parte Anderson, 1987) The death was accidental, but negligence is a factor. As mentioned above, this is legally distinct from neglect which would imply a complete failure to provide any care to the patient during the time in which said patient was dependent upon the hospital. Care was provided, but in the form of treatments leading to a fatal overdose. There are no apparent incentives that would suggest the error to be the result of deliberate action on the part of the patient, or on the part of the pharmacist. Thus negligence contributed to the accidental death of the patient, J. in the absence of actual malice, or evidence of deliberate denial of care and narrative verdict is warranted in the case of J. (West Yorkshire ex parte Sacker, 2004) Specifically, the purposes of this inquest require an exhaustive summary of the circumstances surrounding the death of the patient, ways in which that death might have been prevented and contributing factors. This verdict has attempted to give a factual account of the demise of J, in the absence of deliberate, premeditated actions that were intended to cause death. This would also Cexclude the deliberate withholding of sustenance or treatment. The narrative is an accounting of events and contributing factors, but it is not appropriate in this instance to make a definitive attempt to assign blame in the criminal sense. The primary physician could have been clearer in his prescription. The pharmacy staff could have double checked their assumptions. The chief pharmacist could have insured that those under him operated in accordance with the proper protocols. Nurses at the rest home should have had an opportunity to at least question the dosage, should any of them have been familiar with the standard dosages of this sort of chemotherapy. Again, the principal pharmacist should in all probability face sanction, but his actions were not deliberate, and an attempt was made to provide care albeit grossly incorrect. BIBLIOGRAPHY Dorries, C. (2004) CoronersCourts: A Guide to Law and Practice 2nd Edition OUP Matthews, P (2010) Jervis on Coroners 13th Edition Sweet & Maxwell Matthews, R (2008) Blackstone? Guide to The Corporate Manslaughter and Corporate Homicide Act 2007 OUP Mendenhall, NP. ?he role of radiation in the management of Hodgkin? disease: an update,Cancer Invest 1999; 17:47-55. Potter, R. ?ediatric Hodgkin? Disease,Eur J Cancer 1999; 35: 1466-1477. Thomas, Straw and Friedman (2008) Inquests: A Practitioner? Guide 2nd Edition Legal Action Group Education and Service Trust Limited , ( in this book there are 2 chapters to use in the essay 1. the verdict page 263 2. special cases page 409) van Spronsen DJ, Peh SC, Vrints LW, van Imhoff GW, Poppema S. Clinical drug-resistant nodular sclerosing Hodgkin's lymphoma is associated with decreased bcl-2 expression in the surrounding lymphocytes and with increased bcl-2 expression in the Reed-Sternberg cells. Histopathology. 2000 Nov;37(5):420-6. PMID: 11119123 [PubMed - indexed for MEDLINE] Warner, A (2009) The Coroner? Investigators Handbook 2nd Edition ECRI Institute CASES Amin v Secretary of State for the Home Department; R.( on the application of Middleton) v Coroner for West Somerset; Times Law Reports (Court of Appeal), 18 April 2002. Jordan v UK (2001) 11 E.H.R.C. 1, paras. 103-109. R v HM Coroner for the County of West Yorkshire ex parte Sacker [2004] UKHL 11. STATUTES Portsmouth Coroner ex parte Anderson (1987) 1 WLR 1640 Read More