17Mrs O told us on 24 April 2023 two nurses administered a goserelin implant which was not intended for Mr O. The medication was intended for another patient (patient B) who has a name similar to Mr O.
17. Goserelin is a hormonal implant (also known as Zoladex), it is a type of hormone therapy called luteinising hormone blocker, it reduces the amount of testosterone produced. There are two strengths of implant available, one implant which is given monthly and one that is administered every three months. NICE Guidance NG131 says the implants are used to treat patients with metastases (spread of cancer cells to other parts of the body), or local prostate cancer progression. The implant was intended to treat Patient B’s prostate cancer.
18. Mr O had Alzheimer’s and could not advocate for himself, he would not have known he was being given medication in error.
19. The Trust said two nurses gave Mr O the implant, it explained each nurse believed the other had checked Mr O’s wrist band and checked his date of birth to confirm identity before the implant was administered. It said the medication had been mistakenly administered, apologised for the error and says the treatment Mr O received fell short of the standards it aspires to.
20. We looked in the records and the error is clearly recorded by nursing staff who gave Mr O the implant, the nurse said they realised their error seconds after the implant was placed and alerted a doctor immediately. There is an entry in the medical record by a doctor who also records the incident and acts upon it by requesting advice from colleagues. The nurses also recorded they informed Mrs O of the error.
21. We note the Trust admits a failing in giving Mr O the medical implant and this is material evidence something went wrong.
22. We asked a nursing adviser what should have happened, our nursing adviser said the nursing staff should have checked the patients identity before administering any medication. Our adviser explained the relevant guidance is the Professional Guidance on the Administration of Medicines in Healthcare Settings published by the Royal Pharmaceutical Society. The relevant sections are:
‘7 Registered healthcare professionals who administer medicines, or when appropriate delegate the administration of medicines, are accountable for their actions, non-actions and omissions, and exercise professionalism and professional judgement at all times.
8 Those administering medicines are appropriately trained, assessed as competent and meet relevant professional and regulatory standards and guidance.
9 There are organisational policies and procedures in use for the medicines administration process.
11 The organisation has a procedure to minimise the risks associated with the handling or administration of a medicine.
15 The organisation’s administration procedure is followed. This may include, but is not limited to, checking the following:
15.1 The identity of the patient’
24.The guidance says nurses are responsible for their own actions, the identity of the patient should be checked and crucially they should follow their organisational policy (we consider Trust policy at paragraphs 2.4 & 2.5 is relevant and adheres to the guidance published by Royal Pharmaceutical Society).
23. The Royal Marsden Manual of Clinical Nursing Procedures. Professional Edition (2020) is frequently used to underpin Trust policies and it says at page 828: Patient identification.
‘When administering a medicine, the nurse must be certain of the identity of the patient to whom the medicine is to be administered, and it is recommended that at least two patient identifiers should be used (e.g. check name, hospital number and date of birth). To avoid misidentification of patients, staff should check the patient's identity using an identification wristband, which should meet the nationally required standards for wristbands (National Patient Safety Agency. Safer Practice Notice 0507: Standardising wristbands improves patient safety)’.
24. Nationally required wristband standards (NPSA):
Safer Practice Notice – Standardising wristbands improves safety (2007). ‘This alert identifies the requirement that all NHS organisations in England that use wristbands should only include the following core patient identifiers:
• last name • first name • date of birth • NHS number (if the NHS number is not immediately available, a temporary number should be used until it is)’.
25. NMC standards further safeguard the patient, 4.14 and 4.15 say there is a requirement registered nurses should know what they are administering and what it is for. The goserelin implant was intended to treat prostate cancer and knowing Mr O did not have prostate cancer would have been an additional safeguard.
26. The Trust’s own guidance, Administrations of Medicines, says it is essential to determine the identity of the recipient (of medicines). It also says:
•Where possible, verbally ask the patient name and their date of birth •Visually check the patient’s name band against the prescription.
•Where verbal confirmation with the patient is not possible, identity check can be made with the next of kin or carers if they are present.
27. The Trust’s policy is clear and we are satisfied it corresponds with national guidance.
28. The Trust said the nurses should have checked the name on Mr O wristband against the name on the prescription and they inform us that they did not, each nurse assumed the other had checked Mrs O’s wrist band and confirmed his date of birth with him.
29. We have seen the Trust made an error in administering the goserelin implant to Mr O and we consider this a failing.
30. From speaking to Mrs O we understand this was a worrying event for her and Mr O. We now need to understand the impact of the error on Mr O, this will inform our consideration impact of events on Mrs O. Once we understand the impact, we will then look at our Principles of Remedy to see if the Trust have done enough to remedy the complaint.
Impact
31. As Mr O had advanced Alzheimer’s, he was particularly vulnerable. He was not aware an error had taken place and he was not able to tell care givers if he was suffering any side effects. To understand how Mr O was affected and for how long, we spoke to Mrs O and sought independent clinical impact advice from a second adviser, an endocrinologist. We also relied upon the clinical records taken at the time after the error and relevant clinical research papers to help inform of the effects of the medicine
32. Mrs O explained the Trust made a decision to leave the implant in because once it is implanted it migrates and Mr O would have had to have invasive surgery to remove it which carries a greater risk. Doctors considered Mr O was too weak to withstand a general anaesthetic.
33. The Trust said it expected Mr O’s symptoms to resolve shortly after the expiry of the three-month implant. Mrs O says she feels the symptoms lasted much longer. Here we have a conflicting account of the impact.
34. Mrs O told us Mr O suffered with menopause-like symptoms which included aggressive and uncooperative behaviour, hot sweats, numerous chest and urinary tract infections, pains in his limbs, cramps in his muscles, depression, low blood pressure and a change in sleeping patterns.
35. Mrs O told us after the expiry of three-month period, Mr O still suffered with behavioural changes.
36. Our endocrinology adviser told us, inadvertent use of goserelin is unusual and not a common occurrence, they explained there is no specific guidelines to assist clinicians in this particular scenario.
37. From endocrinology advice sought we understand the common side effects of goserelin injections are as described in paragraph 31, they said rarer side effects include gastrointestinal symptoms and high or low blood pressure.
38. Our adviser told us the hormone changes related to the goserelin would take a few days to manifest, the effect of the goserelin would not be immediately noticeable.
39. The Trust said Mr O had blood tests on 25 April which showed no concerns and he was discharged home.
40. Our adviser said the test used to check on testosterone levels is a serum testosterone levels test and we did not see in the records that this test was performed before discharge.
41. However, our adviser told us, in their professional reasoning, it was not necessary for Mr O to have stayed in hospital due to the implant error, as this could have been managed as an outpatient. Thus, discharging him was a suitable course of action.
42. Mr O was not a suitable candidate for operation; therefore we looked to see what the likely impact leaving the implant in place would have on Mr O.
Severity and duration of symptoms
43. We considered the potential severity of the symptoms. Our adviser told us the side effects of goserelin vary from mild to severe. There was a 2025 clinical study by Hafron et al, (Study of persistence and adherence to ADT in prostate cancer) which, from research of past clinical matters, showed of the group of test subjects taking goserelin only 46% continued with the medication beyond 12 months. This shows the side effects can be significant enough to cause people to stop using it.
44. We considered the length of time the side effects could have persisted for. Our adviser explained although the duration of goserelin implant is stated to be 12 weeks, the speed at which recovery occurs is both variable and slower.
45. A study by Oefelein (Time to normalisation of serum testosterone after 3-month LHRH agonist. The Journal of Urology 1998 160 (5) 1685-1688), on 13 subjects, showed that a single dose of goserelin led to very low testosterone levels maintained for six months and persisted for approximately 12 months.
46. Having been informed by clinical advice, medical papers and the information provided by Mrs O, we consider on a balance of probability there is potential that Mrs O’s account of the effects lasting 12 months could have occurred as clinical papers support this thinking that in a percentage of patients this is a known manifestation. Therefore, we think on this balance that Mr O would have suffered with symptoms for a period of up to 12 months.
Impact on Mrs O
47. Mrs O described to us the severe stress she endured as a result of seeing her husband suffer with these side effects and adverse symptoms. She told us the stress contributed to issues with her gallbladder, Mrs O required emergency surgery to remove a perforated gall bladder during September 2023. Though factually we recognise stress can have a manifest impact on the body including gallbladder we are also acutely aware there are many other factors which come into play here. We simply would be unable to say with robustness or certainty if we can link this particular aspect, though we do not diminish the emotional effect this will have had.
48. In determining severity, we rely on our Severity of Injustice Scale. This is a scale the Ombudsman uses that has six levels of increasing severity such as financial hardship, emotional impacts and physiological impacts. The scale starts at level one with minor frustrations and short-lived experiences up to level six where we see profound failings, loss of life or disability.
49. When reaching a view, we consider the individual circumstances of a complaint and the outcomes a complainant wants. Informed by our own guidance on making decisions we also note it is for the Ombudsman to consider what is fair, reasonable and proportionate.
50. In order to reach that view we also use our Principles for Remedy. The principles focus us on considering remedies that are fair, proportionate and reasonable.
51. Lastly, we consider precedent – by this we mean similar complaints we have upheld and the types of remedy that are associated with them. We do so by searching an internal ‘typology of injustice’ to ensure each remedy is considerate of the individual circumstances of a complaint and broadly aligned to previous upheld complaints.
52. We consider the emotional impact of the events on Mrs O to sit at level three on our scale of injustice due to the duration of the impact suffered by Mr O (12 months) and the severity of symptoms and the emotional worry and distress caused. A level three emotional impact is described as ‘Distress, upset or worry lasting six to 12 months. Significant distress (that is, distress which results in a degree of functional impairment) lasting from a few weeks to three months (or shorter periods where the symptoms are greater). Similarly, we consider the emotional impact of this error on Mr O to sit at level three on our scale of injustice. Certainly, Mr O would have been distressed due to suffering the ill effects of the implant for approximately 12 months.
53. As the impact of these events sit a level three on our scale, we do not consider an apology alone is sufficient to remedy these types of cases. We would want to see improvements to prevent a reoccurrence of the identified failings.