Patient given 10 times too much insulin by nurses suffered seizure

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TWO bungling nurses gave a patient 10 times the prescribed dose of insulin, putting him in a seizure so bad managers feared he might die.

The blunder happened at Drummond Grange Care Home, which was  given the lowest-possible grade by inspectors and ordered to make urgent improvements on Thursday.
Janette Burrell (pictured) gave the man 80 units of the drug when he should only have received eight.
And agency nurse Mary Patricia Lennen failed in her duty to make sure the patient at the privately-run facility in Lasswade, Midlothian, was given the correct dosage.
Janette Burrell outside the hearing in Edinburgh

 

“Resident A”, who was on a ward for adults with brain disorders, was rushed to hospital after the nurses realised their mistake and dialled 999.

Staff at Drummond Grange Care Centre feared the man would not “pull through” and police were called, a hearing of the Nursing and Midwifery Council (NMC) this week was told.

Mrs Burrell has admitted a charge of misconduct and Ms Lennan has admitted failing the check the patient was receiving the prescribed amount of the drug during the October 2011 incident.

NMC case presenter Mary-Teresa Deignan told the hearing in Edinburgh that Mrs Burrell was called from her normal place of work at the care home to give Resident A his insulin.

She said: “What is unclear is exactly what syringe was used but whatever syringe it was contained the wrong dose of insulin.”

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She said: “At 4.00am noises were heard from Resident A’s room.

“He was described as having a seizure by the carer who found him.”

Another nurse confirmed the man was having a seizure and gave him jam and glucose in an effort to stabilise him and an ambulance was called, she said.

Ms Deignan said: “When Mrs Burrell showed the point at which she drew the syringe it was realised he had been given 80 units rather than eight.”

Mrs Burrell was “crying” when she realised her mistake and told a colleague it was “completely her fault,” Ms Deignan said.

Anette Goodfellow, head of the Pentland unit, where the man lived, said in a statement: “I found it extremely difficult to understand how Resident A received an overdose of insulin during the night.

“If either nurse was unsure they should have sought further advice.”

She continued: “I still find it difficult to understand how the mistake happened.”

Fiona Moncur, a manager at the home’s owners, Barchester Healthcare, investigated.

“By the time I arrived the police had been called because the incident was deemed to be an adult support and protection issue,” she told the hearing.

“It was initially feared Resident A might not pull through. I was later advised Resident A had been released from hospital.”

 

Dedicated

Keira Dargie, representing Mrs Burrell, said a Care Inspectorate report revealed there had been another “near miss” when “exactly the same error” was made a few weeks before the incident in question.

Ms Moncur confirmed that another nurse had “drawn up far too much insulin insulin into a single use syringe”.

Mrs Burrell declined to comment outside the hearing. Ms Lennen was not present but admitted the charge in a letter to the NMC.

She wrote: “I know I did wrong, I was a dedicated nurse and I had to give up everything.”

Mrs Burrell denies a further charge of failing to ensure three other residents were given enough to drink during a nightshift in May 2011.

The hearing, before a panel chaired by Anne Booth, will rule on whether to strike off Mrs Burrell and Ms Lennen from the nursing register later this week.

A spokeswoman for Barchester Healthcare, who run the care home, said: “At Drummond Grange care home the safety and wellbeing of our residents is of the utmost importance and we take allegations of misconduct very seriously.

“We can confirm that we dismissed a member of staff in 2011 following an internal investigation.”

The Care Inspectorate yesterday ordered the home to make a range of improvements including staffing and patient care, following in inspection in December.

A spokesman for the watchdog said: “We raised serious concerns about  the quality of care being provided at this service in August last year.“At the time we graded the quality of care as ‘weak’.  

“Our most recent  follow-up inspection found that the quality of care provided has deteriorated to ‘unsatisfactory,’ the lowest grade we can give.

“We have informed the service of what it needs to do to ensure that immediate improvements are made.”

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