Paolino Amico

“The consultant required a discharge plan for oxygen therapy to be in place before Mr [name redacted] could go home. The hospital discharge plan and medications were confusing and the referral for oxygen therapy requirement was unclear, and the PAT testing for the machine was out of date. Paramedics advised the family that the oxygen provided on Mr [name redacted] discharge was low flow and was not meeting his oxygen requirements with his oxygen saturations at 68% and this immediately improved on ambulance crew”

“Mr [name redacted] did not receive his prescribed medications during his second admissions when he was readmitted to hospital on 9 June. a. On 9 June a doctor in Accident & Emergency had reviewed Mr [name redacted] prescribed medications and increased liquid oral morphine sulphate 10 mg in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 hours with slow released morphine sulphate (MST) continued 2 times daily. Trust staff did not administer any morphine to Mr [name redacted] although he and his family were”

“Neither the nurse nor the doctor sufficiently scrutinised the medication prescribed on 9 June or on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily. Mr [name redacted] was not referred for pain management”

“Mr [name redacted] NEWS score increased, and an emergency call was not put out on 11 June when it was established that Mr [name redacted] was unresponsive even to pain from 03:00 hours”

“The on-call doctor was called approximately one hour after Mr [name redacted] NEWS score was found to be 10 and arrived at 07:50, this was not an emergency call. The on-call doctor had not been informed of: a. the deterioration in Mr [name redacted] presentation during the night b. that the family had informed nursing staff of their concerns Mr [name redacted] had been given the wrong medication when he was noted to be unresponsive at approximately 03:00 hours, that should have immediately raised concerns about an overdose”

“Amico morphine overdose was partially treated: a. There was an immediate response to Naloxone but the opioid reversal for overdose was not in accordance with British National Formulary guidelines or with an NHS England alert previously issued. b. There was no consideration or plan for alternative pain management in a patient who had been receiving morphine pain relief as part of his treatment plan for cancer”