Page last updated at 11:39 GMT, Tuesday, 26 January 2010

Overdose deaths at Birmingham hospitals total five

by Michele Paduano
Health correspondent, BBC Midlands Today

Rosemary McFarlane
Rosemary McFarlane died after a routine hospital procedure

Five patients have died at a West Midlands hospital trust following serious errors with medication since 2006, the BBC can reveal.

Four deaths, at Heartlands Hospital in Birmingham, have already been made public.

However, a further death - yet to be publicised - occurred at Good Hope Hospital in Sutton Coldfield.

The Heart of England NHS Foundation Trust, which runs both hospitals, has said all the incidents were "thoroughly investigated", internally and also by the independent Care Quality Commission (CQC).

The information on the deaths are contained in a report by the CQC into 27 "serious untoward issues" at the trust, between March 2007 and June 2009.

We deeply regret that these incidents occurred and would again like to apologise to the patients and relatives of those affected
Lisa Dunn, Heart of England NHS Foundation Trust

It found a number of recommendations following serious untoward incidents had not been signed off, despite the date of completion having lapsed.

In another medical error, a baby was also over-medicated at Heartlands Hospital. The trust said the baby survived unharmed.

The trust has again identified a cluster of serious, untoward incidents within the paediatric service and has commissioned an external review by the Royal College of Paediatrics and Child Health.

Four patients were already known to have died at Heartlands Hospital.

One, Stephen Parkin, died in May 2006, after having wrongly been given a muscle relaxant which was in the wrong box and should not have been on the ward.

Two patients, Paul Richards and Baljit Singh Sunner, died in 2007, after having they were given five times the recommended dose of a fungal treatment, amphotericin.

Letter to relatives

Rosemary Mcfarlane died in 2008 after receiving ten times the concentration of a phosphate solution poured into her lungs.

The trust has said in a letter to the relatives of victims that it has now invited an external review of medicines management, prescribing and drug administration arrangements, and has invited them to take part in the review.

Lisa Richards-Everton, wife of Mr Richards, is taking her concerns to the health minister, Ann Keen.

She wants to see processes normalised across the NHS, so the same procedures are used everywhere, in the hope it will lead to less confusion when junior doctors change jobs.

In a statement Lisa Dunn, Heartlands Hospital Director, said the CQC report had been fully-publicised on the hospital website.

'Case closed'

"They highlighted that we not only thoroughly investigated each incident, we also made changes as a result of the unique circumstances involved in each incident," said Ms Dunn.

"We deeply regret that these incidents occurred and would again like to apologise to the patients and relatives of those affected by medication errors to work with us on an independent review surrounding prescribing and administrating medication within the Trust."

In conclusion, the CQC report states the trust has robust governance arrangements in place and a clear mechanism to investigate and learn from the incidents that occur.

"On the basis of the information provided, the commission does not have any immediate concerns relating to the safety of patients and will close the case," it said.

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