Dispensing error

In Aberdeen, a man aged 78 has died in hospital, after he accidentally took a tablet, which was not intended for oral use. Alan Moir was admitted to Aberdeen Royal Infirmary with leg sores and was later transferred to Woodend Hospital.

A few days ago, he had fallen asleep and on wakening found this tablet lying on his bedside cabinet. This was in fact a desinfectant, intended to be dissolved into water, for bathing his feet. Thinking it looked like one of his painkillers, he swallowed it. The man realised something was wrong and started to scream in terror. He vomited repeatedly, and developed a sore throat. Although he was reported as being fine after the incident, Mr Moir died last weekend. The family is distraught, and are now preparing to bury him next Tuesday.

The incident is subject to a police investigation, as well as one by NHS Grampian as to what went wrong. For this reason, I cannot speculate on the possible cause, although police have stressed that there are no suspicious circumstances.

When you are in hospital, all medication is prescribed by the hospital doctor and given to you for taking by the nursing staff. They sign for administering the drugs, and also note when you have not taken the medicines.

Errors do happen in hospitals. They rarely have such tragic consequences, though. An investigation into an error is not intended as an exercise in finding somebody to blame, but to find out what has gone wrong and why, and which lessons can be learned. An error with fatal outcome involves the Procurator Fiscal (in Scotland) as a matter of procedure.