4. Mr A complains about the Trust’s treatment while his wife was an inpatient in March 2022.
5. Mr A complains about the effect of a 100mg of hydrocortisone injection (a type of corticosteroid used to treat painful and swollen joints) that was given to Ms B by mistake.
6. Mr A thinks this injection contributed to his wife’s death in May 2022.
7. Ms B was transferred to the Trust on 30 March 2022 after having chemotherapy at a Macmillan cancer centre. Staff described her as being ‘short of breath’.
8. On the same day, Trust staff accidentally gave Ms B 100mg of hydrocortisone by injection. This drug was meant for another patient on the ward. The Trust admitted that it made this mistake.
9. Ms B was readmitted to the Trust on 14 April because she was unwell when she had chemotherapy treatment as an outpatient. Ms B later had a scan that showed her cancer had progressed. Trust staff thought Ms B was too unwell for chemotherapy. She was making plans to travel overseas for treatment, but deteriorated before the journey could be arranged.
10. On 12 May Trust staff noted that Ms B was dying due to massive progression of the disease. The Trust began to give end of life care. Sadly, Ms B died shortly after this.
15. We recognise it must have been worrying and distressing for Ms B to be injected with 100mg hydrocortisone that was meant for another patient.
16. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect, which the organisation has not put right.
17. Mr A told us he thinks the accidental dose of hydrocortisone brought on Ms B’s death. Having considered the evidence available, we have not seen anything to support this. We are pleased that we have seen no evidence that Ms B experienced any ill effects from the hydrocortisone.
18. The BNF guidance explains there are many different side effects of taking hydrocortisone. Two of these are high blood pressure and a higher blood sugar level. Our adviser explained that Ms B did show an increase in both of these after having the hydrocortisone injection.
19. NICE guidance explains that people who take corticosteroids for more than three weeks are at risk of more serious or long-term side effects. It explains the effects of hydrocortisone are ‘short’ with a half-life of around eight to 12 hours. This means that within eight to 12 hours, the amount of hydrocortisone in the body will have reduced by half.
20. Our adviser explained that although Ms B’s medical records did show a slight increase in her blood pressure and blood sugar levels, these symptoms continued long after the effect of the hydrocortisone will have worn off. This suggests that something else was causing the increases.
21. Our adviser explained it is unlikely that Ms B’s high blood pressure and blood sugar were caused by the hydrocortisone injection but were more likely to be a natural symptom of her condition (cancer) getting worse.
22. We can see no evidence that the hydrocortisone had any significant or long-term effect or caused Ms B’s death.
23. We recognise the medication error caused Mr A and Ms B great worry and stress and left Mr A with serious concerns. This is an injustice.
24. Our Principles say to put things right organisations should, ‘provide an apology, explanation, and an acknowledgement of responsibility, as well as remedial action, which may include reviewing or changing a decision on the service given to an individual complainant; revising published material; revising procedures, policies or guidance to prevent the same thing happening again; training or supervising staff; or any combination of these.’
25. The Trust has acted in line with our principles by apologising for the medication error and for the stress and anxiety it caused. The Trust has offered a financial payment of £500. This is in line with what we would recommend in a similar case where the failings affected a person in a similar way.
26. As we are satisfied the Trust has already taken appropriate action to put things right, we have decided not to take any further action.
27. We are grateful to Mr A for taking the time to tell us about his difficult experience. We hope our decision gives him and his family some closure.
1. We investigated Mr A’s complaint about University College London Hospitals NHS Foundation Trust (the Trust). We are sorry to hear about the impact that his wife’s, Ms B, treatment had on the family. We are sorry to hear about Ms B’s death.
2. We have carefully considered this complaint and have decided the Trust has already done enough to put right the impact of what went wrong. And, we have seen no evidence that the drug error had a negative clinical impact on Ms B.
3. We understand why Mr A is so concerned about what happened. We hope the information in this statement gives him reassurance that we have seen no evidence that his wife’s death was related to the drug error.