Wisborough Green mother believes son was ‘badly let down’

Mary-Anne Hardie said her son Hamish had been looking forward to job interviews and starting a new chapter in his life when he died at home in Wisborough Green in August last year.

The 30-year-old accidentally overdosed on medication for severe back pain he received at Loxwood Medical Practice, an inquest at Crawley Coroner’s Court heard on Wednesday.

SEE MORE: West Sussex man died from an accidental overdose following ‘unfortunate’ errors with medication

After the inquest, Mrs Hardie said: “We still feel that Hamish was badly let down that day and that his life was unnecessarily cut short by medical failings.”

The inquest heard that Hamish had been given a prescription of oramorph, dihydrocodeine and diazepam but the dosage was not written on the oramorph bottle, with ‘use as directed’ written instead.

While it was initially a computer error which led to the vague instruction on the bottle, it was not fixed by trainee GP Dr Carlos Novo, nor was it picked up on by the dispensing practitioner within the pharmacy at the practice.

Mrs Hardie took responsibility for administering the medication, but the uncertainty about the Oramorph label and reliance on Hamish for dosage details meant that more frequent and higher doses were given.

Hamish died two days later.

Mrs Hardie said: “If the labelling and prescription advice had been clear, or the pharmacy had spotted the inconsistency, then we feel that Hamish would still be here as he was looking forward to job interviews and a new chapter in his life.”

Specialist solicitor Tim Deeming of Tees Law said: “The Coroner described this as a perfect storm and it is tragic that the GPs did not know that the labelling system defaulted, and that the pharmacy did not then spot this.

“While we are glad to know that the Loxwood Medical Practice has made significant changes to procedures following Hamish’s death we all hope that the NHS and GPs will take steps when providing such prescriptions to provide clear guidance on use, as well as checking computer systems to ensure that other families do not have such devastating outcomes.”

Giving her conclusion at the inquest, in which she offered her condolences to the Hardie family, Karen Henderson, the assistant coroner for West Sussex, ruled a verdict of an accidental overdose on prescribed medication.

She said: “This was a clinical error, compounded by a further lack of clarity in how much was given.”

However, Ms Henderson did note that there was no evidence to suggest that the surgery had been negligent, due to the ‘prompt assessment and thorough treatment’ given to Hamish.

On the subject of preventing future deaths, the coroner said she was satisfied the surgery had implemented procedures to ensure the same mistakes would not be repeated.