Computer labelling error on prescription bottle led to fatal dose of painkillers

A computer labeling error on prescription drugs caused a 30-year-old man with a slipped-disk to take a fatal amount of painkillers, an inquest heard.

Hamish Hardie, who worked as a public relations consultant, was prescribed the powerful drugs last August while he was waiting for surgery on two prolapsed lumbar vertebral discs.

But his mother, Mary-Anne Hardie, told an inquest said her son had been ‘badly let down’ after a computer error meant the medication was only marked with ‘use as directed’ instead of the correct amount.

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

As a result the Leeds University graduate died at the family home in Wisborough Green, West Sussex, last August – just two days after he started taking the incorrectly labelled medication.

While it was initially a computer error which led to the vague instruction, this was not fixed by trainee GP Dr Carlos Novo, nor was it picked up on by the dispensing practitioner within the pharmacy at the Loxwood Medical Practice in Billingshurst, West Sussex, the inquest at Crawley Coroner’s Court heard 

A post-mortem confirmed that the primary cause of death was a prescription drug overdose.

Giving her conclusion at the inquest, in which she offered her condolences to the Hardie family, assistant coroner for West Sussex Karen Henderson, gave a verdict of 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 noted 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.

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