El Alamein and Tobruk veteran dies after drugs mix up

Antipodean Andy · Jun 4, 2008

War hero, 90, in hospital for routine knee operation died after nurse gave him WRONG drug | Mail Online

A World War Two war hero who went into hospital for routine knee surgery died after a nurse gave him deadly drugs by mistake.

Joe Gibbs, a Desert Rat who fought at El Alamein, was one of at least three people to die in hospital since 2000 because of the same confusion over drug packaging.

The 90-year-old widower had a massive heart attack after the lethal cocktail of epidural medicine was pumped straight into his bloodstream, his inquest was told.

It also heard there were more than 20 other similar cases across the country where patients had survived despite the error.

Mr Gibbs, from east London, became a sergeant and acting sergeant major after first joining the army in 1940 and fought at El Alamein and Tobruk.

After the war, he worked in the East End docks and was then in charge of security for the Royal Corps of Commissioners at a clothing factory until he retired aged 80.

The pensioner was recovering from a successful routine knee replacement operation at Newham General Hospital when a senior nurse made the fatal error.

His operation had gone well but it was decided to move him to the main hospital's intensive care unit after the surgery because of his age and medical history.

His anaesthetic was wearing off when he arrived and he was given a top-up of bupivocaine in an epidural catheter to ease the pain, Walthamstow Coroner's Court was told.

When he suffered a dangerous drop in blood pressure, senior nurse Rajpattee Samraj, mistakenly attached the drugs to a drip which flowed at speed into Mr Gibbs.

Mrs Samraj had been on duty for around 10 hours when she made the fatal mistake of mixing up the epidural and intravenous types of the drug.

The two drug bags look very similar, are the same size and both contain clear liquid but one has a small strip saying for 'epidural use only', the inquest was told.

A vital final check should have been made by staff at the patient's bedside to ensure the right medicine was administered but this was not done.

The pensioner suffered immediate seizures and a heart attack. Doctors battled to save his life for an hour before he died.

Both the coroner and the Trust's medical director Dr Mike Gill said he would not have died if the crucial last check had been made.

The drug would have been enough to kill a healthy, young man let alone a war hero who had a 'very, very seriously diseased heart', the inquest heard.

Mrs Samraj, who had a spotless 13-year record as a nurse, apologised to his family at the inquest.

She said: 'Not a day goes by when I don't think about what happened. I wish I could turn the clock back.'

Prof David Cousins, head of safe medication practice at the National Patient Safety Agency, revealed at least three other people had died in similar circumstances.

He told the hearing two were in operating theatres in Liverpool and Brighton and the third was in Swindon in 2004 involving a mother who had just given birth.

Coroner Dr Elizabeth Stearns said she would take the unusual step of writing to the appropriate authority and do 'everything I can to make it less likely that such a tragic incident can happen at any time in the future'.

She added: 'It's still possible legally to put bags on the market that are identical. If nobody buys the product, they'll change.'

Prof Cousins seriously criticised the poor design of drug packaging, claiming it was 'remarkable' more mistakes were not made.

He said: 'We're talking senior doctors and nurses with usually exemplary records where because of the product design and processes involved have made a simple mistake with fatal consequences.

'There's a lot of legislation relating to medicines and all the legislation is to make sure that the medications are pure and not tainted, but no allowance in the industry that these are going to be handled by human beings.

'Manufacturers can design all the packs to be identical because they~re proud of their corporate logo. To me, it's remarkable that healthcare practitioners get it right so much of the time when dealing with products that are so poorly designed.'

Newham Hospital Trust now uses different bags following the tragedy, which the coroner ruled was accidental death.

His distraught daughter Josie Mills and her son Jason spoke out last night after the coroner recorded a verdict that he died in an accident.

Mr Mills said: 'It's worrying how often this has happened. It was foreseeable - therefore there was a chance to stop it happening.'

'I think it was probably the only verdict that could be possibly recorded. It was clear the nurse didn't intend to take my grandfather's life.

'We just hope something gets done now within the industry. It's so fundamental.'

Mrs Mills, of Basildon, Essex, said: 'I'm very cross that the nurse never checked it at the bedside. I'm really hurt about that.'

'My father was very, very active. He loved dancing and gardening as well as enjoying painting, writing poetry, and going on day trips.'
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spidge · Jun 4, 2008

I remember when my wife was in hospital, nurses did cross checks on drips etc!

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