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Opiates warning after OOH death

GPs have been warned to be more vigilant when administering intravenous medication, especially opiates, after an out-of-hours doctor killed a patient by accidentally injecting her with too much diamorphine.

The GP who made the error, Dr Michael Stevenson, 54, last week received a 15-month prison sentence, suspended for two years, after admitting the manslaughter of 58-year-old grandmother Marjorie Wright. Dr Stephanie Bown, director of education and communications at the Medical Protection Society, said the death was 'an absolute tragedy for everyone concerned'. She warned GPs should be 'extra vigilant' as they worked in the community and would not necessarily be able to get a colleague or nurse to double-check dosage, as was the case in secondary care. She said as a 'general rule' she would encourage doctors to know what was in their bag – which could be more challenging for locums or out-of-hours doctors using borrowed bags. She added: 'It would be a matter of good practice and very sensible after administering any medication to wait and make sure the patient is fine, in particular with an opiate.'Last year the National Patient Safety Agency revealed that between 2000 and 2005 seven case reports were published of deaths due to the administration of high-dose diamorphine or morphine to patients who had not previously received doses of opiates. Many of these incidents involved diamorphine and morphine 30mg ampoules being selected in error for lower-strength ampoules and causing overdoses.Dr Stevenson, from Bootle, in Cumbria, had been working for out-of-hours provider Cuedoc when he injected Mrs Wright with 30mg of diamorphine instead of 5mg on 30 January 2005. The patient's daughter had called the doctor because her recently widowed mother was suffering from a migraine.Preston Crown Court heard that Dr Stevenson failed to wait to monitor Mrs Wright's reaction to the drug. Minutes later, she was dead. The GP realised his mistake later in the day and confessed to a colleague. The court heard that the GP had been working an average of two double night shifts a day for each of the two weeks preceding Mrs Wright's death.But Cumbria PCT told the court Dr Stevenson worked only a fraction of those hours and had not been overworked.

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