Family considers action after patient death

The fatal dose was given at the University Hospital of Wales

The family of a kidney patient, from south Wales, who died after a nurse gave him a massive overdose of drugs are considering suing the trust involved.

A coroner recorded an open verdict on retired miner Thomas Martin, from Rhondda, after he received an overdose of an anti-clotting drug at the University Hospital of Wales.

The hospital is to blame and admit themselves that mistakes were made

Son Paul Martin

A nurse, from Finland, who was unfamiliar with the equipment, administered a 50-hour dose of heparin in just two hours at the hospital in Cardiff.

Mr Martin's family are now considering taking legal action against the Cardiff and Vale NHS Trust.

An inquest in Cardiff on Wednesday heard the drug was administered by an agency nurse who had not been in the UK "very long".

Suzanna Brusoyri did not know how to operate the infusion device to automatically give Mr Martin a set dose each hour.

Kidney failure

By the time the mistake was realised it was too late Mr Martin, 60, who had been admitted to the hospital kidney failure, died two days later.

At the inquest Doctor Kesh Baboolal said: "Mr Martin became very unwell while having dialysis and one diagnosis was that he could have developed a clot that had passed to the lung.

"The treatment was to dissolve it using heparin. The drug would normally be given by a nurse, at a rate of 400 units an hour."

The inquest was told the prescribed dose of 20,000 units should have taken 50 hours - but was given the whole amount in just two hours.

There are both natural and unnatural elements and it is difficult to separate them

Coroner Dr Lawrence Addicott

He added that Mr Martin "had a very poor prognosis" as he suffered heart, lung, and kidney problems.

Managers at the hospital said a policy change now ensures all nurses are trained to use infusion devices properly.

Mr Martin's wife Margaret, 59, decided to turn off his life support machine after tests showed extensive brain damage.

Cardiff and Vale of Glamorgan coroner Dr Lawrence Addicott said: "The proper method of giving the infusion was not followed.

"The nurse did not inquire with regard to infusion devices. She chose to administer the drug herself.

Unhappy

"The consultant in charge of Mr Martin was not informed until much later and he feels if he had time to give an antidote, it might have helped."

But Dr Addicott said the many illnesses Mr Martin suffered from had contributed to his death as much as the heparin overdose.

He said: "There are both natural and unnatural elements and it is difficult to separate them."

After the hearing, Mr Martin's son Paul said the family were considering suing the hospital.

He said: "We are not happy with the verdict. The hospital is to blame and admit themselves that mistakes were made.

"We thought today would bring the matter to a close but instead we have been left with even more questions."