Cancer patient wrongly given alcohol withdrawal drug, ombudsman reports
Family says time lost with patient before her death due to drowsiness from medicine
Ombudsman Peter Tyndall says 'the biggest worry' in the case was that the hospital was not 'able to say which doctor had actually prescribed the medication'. File photograph: iStock
A cancer patient was given medication designed for alcohol withdrawal, despite the fact the patient had not drank in 10 years, according to a case study in the ombudsman report – with the patient’s family saying side effects from the medication meant they missed precious time with her before her death.
Ombudsman Peter Tyndall said “the biggest worry” in this case was that the hospital was not “able to say which doctor had actually prescribed the medication so we had to ask them to tighten up the way they dealt with that”.
His final annual report as ombudsman has shown complaints about public services, local authorities and the Health Service Executive remained high throughout 2020 despite the Covid-19 pandemic.
Mr Tyndall received 3,418 complaints from the public last year, which was 6 per cent lower than the 2019 figure but still relatively high.
In the case of the cancer patient, a woman named Sarah complained to the ombudsman after her late mother, Norah, was prescribed medication for alcoholism and alcohol withdrawal as part of her emergency cancer treatment.
“Norah had attended the emergency department of the Mater Hospital with severe pains in her stomach and jaundice,” the case study said.
“While giving her medical history to the hospital, she made it clear that she did not drink alcohol.
“Norah had a previous history of cancer and the medical team admitted her to hospital for further tests. An ultrasound confirmed that Norah had liver cancer.”
Later that night, Norah was given two medications that are commonly prescribed for individuals who have a history of alcoholism and for the treatment of acute alcohol withdrawal.
Her family later noticed that she was drowsy and confused, and they spoke to the nursing team about their concerns.
A doctor then came to review the situation. The doctor noted that Norah had not drank alcohol in 10 years and stopped the two medications.
Norah’s family complained to the hospital that she had been wrongly prescribed this medication.
A short time later Norah died. The family felt they had missed precious time with her because she was drowsy from the side effects of the medication.
The hospital acknowledged that Norah was wrongly prescribed the two medications, but it was unable to identify the doctor who had written the prescription.
The prescription was initialled, but with no Irish Medical Council registration number.
Norah’s daughter, Sarah, made a complaint to the ombudsman as she felt that the hospital should have been able to identify the doctor.
While the hospital had apologised to Norah’s family, it was unable to provide an explanation as to why the medications were prescribed because it was unable to identify the doctor who wrote the prescription.
Various efforts were made to try to identify the doctor, including speaking with the doctors that were working that day, completing a medication variance report form and comparing the initials on the prescription with the hospital’s signature bank. An incident form was also completed.
However, the ombudsman said these actions were taken only after receipt of a formal complaint from the family, as opposed to immediately after the medication error was identified.
The ombudsman said that the incident form should have been completed immediately and greater efforts should have been made at that time to identify the doctor.
The hospital has since implemented more staff training in relation to prescribing and incident reporting.
The ombudsman also expressed concern about Ireland’s continued reliance on congregated settings, especially with regards to people with disabilities and international protection applicants. A congregated setting is where 10 or more people with a disability are accommodated in a single living unit or where people are placed in accommodation that is campus based.
There was a massive decrease (64 per cent) in the number of complaints made by people living in direct provision. Mr Tyndall believed the decrease was linked to his office’s inability to visit direct provision centres to hold outreach clinics in person, however.
“This demonstrates the importance of our outreach work in reaching this vulnerable category of the population, which had to be severely curtailed in response to the pandemic,” the report read.
In 2020, government departments and offices were the source of 32 per cent of complaints. Local authorities were the subject of 26 per cent of complaints, which mainly concerned housing issues, and 18 per cent of complaints arose from the health and social care sector.
Within the complaints concerning government departments, 735 were about the Department of Social Protection, and 131 of those complaints concerned Covid-19-related payments.
Speaking on Newstalk Breakfast, Mr Tyndall said: “We saw PUP [Pandemic Unemployment Payment] complaints come in – in the early days there were quite a few of those – people saying they were entitled to it and not getting it. Some of that was due to the fact that there wasn’t an appeal mechanism in place.
“Normally with social protection complaints people can appeal the decision before they come to my office but we worked with the Department and now there is an appeal mechanism in place. By and large that’s settled down.”
There were 163 complaints about the Department of Agriculture, Food and the Marine, 99 about the Office of the Revenue Commissioners and 68 about the Department of Education.
Mr Tyndall also announced on Wednesday that this will be his final annual report, as he plans to retire from his position as ombudsman after almost eight years. “It’s a hugely privileged job – there’s not many jobs where you can make a difference to people’s lives or make public services better for everyone, so I’ve greatly enjoyed the opportunity it’s given me,” he told Newstalk.