Camden New Journal - News: ‘Culture change’ at Royal Free after man’s death

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Camden New Journal - by CHARLOTTE CHAMBERS
Published: 04 October 2007

‘Culture change’ at Royal Free after man’s death

THE Royal Free hospital in Hampstead has made a series of changes after a patient died after accidentally being given an overdose of painkillers, an inquest has heard.
Dr Timothy Peachey, a director at the Pond Street hospital, gave evidence from the witness stand during a hearing into the death of Spencer Ward at St Pancras Court on Thursday.
The patient, 39, died last June after he was given an accidental overdose of morphine, a painkiller.
Dr Peachey said the hospital’s directors had tried to make changes to the hospital’s “culture”.
He said: “We felt it important to reference the fact that doctors are not above being challenged. When they say things they are not always right. The culture of challenging people in senior positions is difficult to embed and it’s not just a problem in medicine but in many systems.”
Mr Ward died after he was given 24 times the recommended amount of morphine following his admittance for a terminal cancer. The accident happened after blood expert Dr Philip Lodge miscalculated the conversion from one type of painkiller into morphine.
Although nurses and another doctor expressed surprise at the large dose suggested by Dr Lodge, the amount went unquestioned.
Since Mr Ward’s death, the Royal Free has changed the rules to ensure more than one doctor calculates conversions between substances.
Coroner Dr Andrew Reid ruled Mr Ward, a bill-plasterer who lived in Enfield, died from natural causes due to the extent his cancer had taken hold. “I’m satisfied that on the evidence Mr Ward died when he did as a result of an adverse event but he would have died in the next few day,” said Dr Reid.
Giving an emotional account of her husband’s death, student nurse Susan Ward said: “He was doubled up on the floor. He was a big man who could take pain but he was in agony.
“He was really fit – for his job he had to be. We didn’t get told until the day before he died that he was going to die, and that he had a week to live.”
Dr Reid also singled Dr Lodge out for praise, suggesting it was only the second time in his career a doctor had highlighted their own mistake that would have gone unnoticed otherwise. “But for the doctor notifying us... the opportunity for learning would have been lost.”
A Royal Free press officer said: “The trust would like to express its apologies and condolences to Mr Ward’s family. The coroner commended the trust for the changes implemented and the audits of them. He also commended the consultant who had made the calculation error, stating that he had shown good professional conduct by reporting this matter to the Coroner and the medical director.
“Only through his reporting of this matter had the changes needed in the service been highlighted and the improvements made.”

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