Solution containing dextrose used by mistake – £7,500

Mr Jones was admitted to hospital with left leg cellulitis, shortness of breath, constipation and a distended abdomen. A preliminary diagnosis was made of abdominal malignancy and acute pancreatitis.

During his stay in hospital, his condition deteriorated and he suffered an intraperitoneal bleed. A potential incident was identified and reported to the family – dextrose containing solution had been mistakenly used in the arterial line flush, resulting in erroneously high glucose readings, and administration of large doses of insulin had caused undetected hypoglycaemic brain injury.

Mr Jones’ condition remained critical and, with the family’s agreement, all resuscitative measures were withdrawn and he was pronounced dead on 19th February 2011. Following investigations neither the police or the Health and Safety Executive decided to take enforcement action. The verdict of inquest was accidental death contributed to by neglect.

Posted in Medication errors