When you or a loved one go to hospital, you would hope and imagine that you would get the best care possible.
That means getting the right procedure from a capable doctor, being cared for being a responsible nurse and getting all the right medications.
But for one patient, that sadly did not happen – and it eventually led to his death.
Paul Lau was a healthy 54 year old man. He was in hospital to get a routine knee surgery.
However, six hours after undergoing his knee construction, Lau died from a drug overdose.
It turns out that during his stay at Macquarie University Hospital in June 2015, Lau was accidentally given a stronger medication that was actually meant for someone else.
This kind of medication should have never occurred, and is currently being investigated in a four-day inquest in the NSW Coroners Court
The inquest is to see why such an error was made – and to learn from the incident to make sure nothing like this ever happens again.
New Software and Poor Training
During the inquest into Lau’s death, it was revealed that the hospital had introduced a new software for prescribing medication – TracCare.
“There was a serious prescribing error during the surgery, and then a failure to detect that error,” said Counsel Assisting the inquest, Kirsten Edwards.
Reportedly, Lau’s anaesthetist mistakenly logged a stronger pain medication, that was meant for someone else, into Lau’s electronic chart.
The mistake went unnoticed by the anaesthetist and the numerous nurses that were on duty.
When questioned, it was revealed that the anaesthetist had not received any formal training on how to use the hospital’s new software.
Systems need to be in place, guidelines need to be standardised – and having everyone get proper training is essential.
There were reportedly several indications that the medication prescribed for Lau was inappropriate for his routine knee surgery, but no one chose to question what was on the chart.
In fact, when the anaesthetist checked on Lau, hours after he was given his medication, he did not follow up as to why Lau was wearing a pain patch that he did not prescribe.
“None of these health professionals are on trial,” Ms Edwards emphasised.
To the credit of all the hospital staff involved, the staff had co-operated fully with the inquest and investigations by the hospital.
“People involved in the care of Paul have been responsible and accepted they made mistakes.”
“Your honour might find there were more than 15 missed opportunities to detect that prescribing error and save Paul’s life,” Ms Edwards told the inquest.
“These sorts of deaths just shouldn’t happen in a modern, advanced, medical facility.”
The inquest before Deputy State Coroner Teresa O’Sullivan has been set down for four days.
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