Bright graduate died after GP practice dosage error

West Sussex Assistant Coroner Ms Henderson has concluded an Inquest into the tragic death of a 30-year-old man who had been receiving medication for severe back pain at a village medical practice. It points to shortcomings in the treatment given by the practice in Loxwood. 

This week’s hearing and an adjourned hearing at Crawley in January learned that Leeds University graduate Hamish Hardie died in August 2019 at the family home in Wisborough Green from an accidental overdose of prescribed painkillers, for which the dosage label was unclear. 

Hamish required pain relief for severe back pain caused by two prolapsed lumbar vertebral discs, for which he was waiting for private surgery, and was dealt with at Loxwood by a qualified doctor who was in his final year of GP training under the supervision of a senior GP. 

Dosage not specified 

The doctor prescribed two opiate painkillers, Dihydrocodeine and Oramorph, as well as the relaxant Diazepam. The prescription for the Oramorph on the label tragically said it should be taken as directed, which was unclear. Sadly, this was also not identified by the dispensing practitioner within the pharmacy at the practice. 

Hamish’s mother Mary-Anne took responsibility for administering the medication, but the uncertainty about the Oramorph label and reliance on Hamish for dosage details meant that more frequent and higher doses were given. 

Sadly, Hamish died two days later and a post-mortem confirmed that the primary cause was a prescription drugs overdose, which the Coroner concluded was accidental. The trainee and supervising GPs did not recall seeing an alert on the medical records and the computer system meant that with an Oramorph prescription its labelling default standard was ‘use as directed’. 

“We still feel that Hamish was badly let down that day and that his life was unnecessarily cut short by medical failings,” Mary-Anne Hardie reflects. “It was May 2019 when Hamish developed back pain from a suspected slipped disc. That was confirmed on an A&E visit in June, when he was given Diazepam and put on the list for a possible operation. We are disappointed that the GPs did not see the alert on the computer and that if the labelling and prescription advice had been clear, or the pharmacy had spotted the inconsistency, then we feel that Hamish would still be here as he was looking forward to job interviews and a new chapter in his life.” 

A ‘perfect storm’

Specialist solicitor Tim Deeming of Tees Law adds: “The Coroner described this as a perfect storm and it is tragic that the GPs did not know that the labelling system defaulted, and that the pharmacy did not then spot this. 

“While we are glad to know that the Loxwood Medical Practice has made significant changes to procedures following Hamish’s death we all hope that the NHS and GPs will take steps when providing such prescriptions to provide clear guidance on use, as well as checking computer systems to ensure that other families do not have such devastating outcomes.” 

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