Pain killer overdose causes catastrophic brain injury

16 Dec 2019

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A woman suffered a catastrophic brain injury after she was accidentally given a ‘toxic’ overdose of an unlicensed and unapproved drug while in intensive care.

Yvonne Hewitt, 54, underwent surgery to fix her ureter, which was damaged in a previous operation, but was given a dose of lidocaine so high that she had two heart attacks. She died two years later from organ failure, but her family say she effectively died that day.

To compound overdosing Yvonne nurses failed to notice she was having a heart attack for several minutes as the alarm in her heart monitor was muted. This led to her suffering an unrecoverable brain injury.

A serious incident report into the blunders at University College London Hospital (UCLH) revealed that nurses gave Yvonne a dose of lidocaine for pain control – a drug that had not been approved for use by the hospital’s use of medicines committee – that was meant for a patient who had an irregular heartbeat. This was a dose much higher than Yvonne could cope with.

Nurses administered the wrong amount as there was no information on the two types of dosage on the ICU computer system – despite a ‘near miss’ three months before when another patient was almost given an incorrect dosage.

Yvonne’s family are taking legal action against and are being advised by solicitors from London law firm Osbornes Law.

Yvonne’s sister Dianne said: “I feel like there was an institutional failure by the NHS in my sister’s case as she was failed from start to finish. There were just so many horrors that she had to deal with and they ultimately killed her, and although she died two years later, I feel that the people who were meant to care for her in UCLH struck the final blow.”

Yvonne, who was from Woodford Green, Essex, first went into Homerton Hospital, East London, in April 2015 to remove her right ovary, but suffered internal bleeding when her ureter was severed. She went into septic shock and was rushed into intensive care, but managed to pull through. The following month she had a nephrostomy – a tube and a bag – inserted.

On December 9, 2016 Yvonne was admitted to UCLH, in Central London, to repair her ureter and was then transferred to intensive care at Westmoreland Street, also part of UCLH.

Dianne said: “She was apprehensive about the operation, but she was excited about getting her life back. I thought we were almost there, and we were. The operation was a success. She was in a lot of pain and said that she felt like she had been kicked in the chest by a horse. She was in good spirits and laughing despite the pain she was in as that’s the kind of person she was. When I left her she was fine and there was nothing untoward. I felt happy to leave her as she was in the ICU, the best place to be and the place where they keep people alive. I said I would see her in a few hours, and I never spoke to her again.”

Yvonne’s husband Owen added: “The operation seemed to have gone well but she said she was in a lot of pain. When I left her I told her to try to stay strong until the morning. The last thing that she said to me was that she was going to be okay.”

Dianne and Owen were later told that Yvonne had suffered a catastrophic brain injury.

Owen said: “I just broke down. I was saying that she was fine when we left her the previous night so how could things have gone so wrong?”

Dianne added that her and Yvonne’s mother, who was ill at the time of the UCLH incident, became so depressed and scared that she refused treatment after that point as she no longer trusted doctors. Subsequently, her condition became terminal.

She said: “My mum refused to have any treatment for her condition or anything to do with hospitals after what happened to Yvonne. She never knew if Yvonne got better and Yvonne never knew if mum got better. But the truth is that my mum never got over what happened to Yvonne. I feel that my mum is a direct victim of their negligence. She never got over it. Mum stopped fighting and I feel she died as a result of what the NHS did to Yvonne.”

It was only when the family was given the SI report that the full horror was revealed and has left Dianne with more questions she needs to be answered.

Dianne said: “I really want to know why they turned the volume down on the machine. I still don’t know who the junior doctor was on duty that night and if they or anybody else has been held to account. I can’t move on until I’m told these answers.

“There was a near miss in October when the nurse checked about using the drug on somebody and the pharmacist told them that it shouldn’t be used. Why did this not happen in my sister’s case? It makes you think that they didn’t take this near-miss seriously and my sister suffered terribly as a result. If they had taken this seriously then she would still be here today.”

Owen said: “I lost my best friend when Yvonne suffered that brain injury and my life has never been the same. How could they have given her a drug that wasn’t even approved and which led to her having two heart attacks? It is the negligence of the worst kind and I am devastated by what happened.”

Yvonne was eventually transferred to the Henry Nihill House care home in Edgeware. She was admitted several times to Barnet Hospital and died there in April this year from multiple organ failure.

UCLH has admitted liability in the case.

Stephanie Prior, head of medical negligence at Osbornes Law, who is representing the family, said: “This is a truly horrendous case where a catalogue of errors left a healthy woman with a catastrophic brain injury and, to all intents and purposes, ended her life. It is simply inexcusable that Yvonne was given a toxic dose of an unlicensed and unapproved drug in intensive care – the place she should have been safest. We are pleased that the trust has admitted liability, but we would urge that procedures are put in place across the NHS to ensure that a tragedy like this does not happen again.”

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