Hospital apologises after patient dies from morphine overdose in Harlow
Th errors in the morphine prescription contributed to the cancer patient’s death.
A hospital in Harlow has apologised after a 63-year-old cancer patient died following a morphine overdose caused by a prescription error.
Paulino Amico died on 12th June 2024 at Princess Alexandra Hospital after receiving multiple accidental overdoses of morphine between 10th and 11th June that year.
Essex coroner Sonia Hayes ruled that Mr Amico’s death was hastened and contributed to by these overdoses, stating that the prescription error was not scrutinised.
Mr Amico, who was suffering from metastatic bladder cancer that had not responded to treatment, was admitted to the hospital on 9th June 2024 with severe pneumonia.
On 10th June, a doctor altered his prescription in the emergency department without seeing him in person. Later that afternoon, during a medical review, his medication chart was not sufficiently reviewed. This error led to Mr Amico receiving six doses of morphine sulfate tablets within 24 hours, rather than the intended two.
Attempts were made to partially reverse the effects of the overdose using Naloxone, an opioid reversal drug. However, these efforts were not in accordance with British National Formulary guidelines or an NHS England alert. Mr Amico experienced acute withdrawal syndrome as a result.
Jo Ward, Interim Chief Nurse at Princess Alexandra Hospital, expressed apologies and condolences to Mr Amico's family, acknowledging the tragic errors in his treatment.
Ms Ward said the hospital has implemented several changes to prevent similar incidents, including:
- Updating electronic systems to prevent inaccurate morphine prescriptions
- Introducing mandatory medicines administration refresher training for nurses
Ms Ward added: “We are committed to not only learning from this incident but taking strong action. We welcome the coroner’s comments and suggestions and will be issuing a full response to the coroner on actions taken.”
The coroner concluded that Mr Amico’s morphine reversal and subsequent pain relief were not managed in accordance with guidelines, contributing to his death.