Drug caused surgery complications

The hospital took a long time to respond to patients' complaints

Three patients suffered heart and breathing problems during minor surgery after being given an unlicensed drug preparation, a report has revealed.

One man had to be transferred to intensive care as a result of the incidents at Ysbyty Gwynedd, Bangor.

The Public Service Ombudsman for Wales upheld complaints by all three patients about the problems in April 2003.

North West Wales NHS Trust said it was taking professional advice and would discuss the report with the ombudsman.

The commonly-used preparation, containing cocaine and adrenaline and known as Moffett's Solution, was given when the three patients had minor operations on the same day at the hospital in Bangor.

The BBC Wales Welsh language current affairs programme Llinyn Mesur obtained a copy of the report by the ombudsman, which has now been published.

Poor handling

It describes how the three patients were treated on the same day and had expected to be discharged by the end of the day.

But two of them suffered severe complications as a result of the solution, which is a commonly used preparation made by medical staff.

The ombudsman criticised the response by the North West Wales NHS Trust, which runs Ysbyty Gwynedd, which did not provide a formal response to the patients' complaints until November 2003.

Despite further respresenations from two patients, the trust remained unable to provide them with an explanation for their reactions.

The trust said it was to discuss the report with the ombudsman

The patients' case was forwarded to the ombudsman, who upheld all three complaints and found the the trust's response to one of the patients was one of the worst examples of poor complaint handling by a trust he had ever seen.

The ombudsman also found that while Moffet's solution was an unlicensed preparation it was used routinely in a number of UK trusts, but its use was considered controversial.

He concluded the solution had been responsible for bringing about the patients' adverse reactions.

The report found there was "no formal protocol for making up the solution, and that medical staff were making the solution up inappropriately".

Dr Rick Greville, director of the Association of British Pharmaceutical Industries, told BBC Wales it was not unknown for unlicensed drugs to be used to treat patients.

"The responsibility of usage of medicines sits with the doctor so if the doctor is sufficiently experienced with medicines that aren't licensed for that type of patient, the medic concerned would perhaps prescribe that medicine," he said.

The ombudsman's report also found failings in the way the trust investigated and responded to the matter as well as a failure to respond to an incident four weeks earlier also involving the incorrect administration of Moffett's solution.

He has recommended redress payments totalling £7,000, plus an extra payment of £500 to the patient whose case he highlighted as being particularly poorly dealt with.

The trust said in a statement it was now taking professional advice in relation to the cases, and it would be contacting the ombudsman in the near future to discuss the findings of the report.