"Potassium Overdose at Good Hope"

About: Good Hope Hospital

(as a relative),

My Mum was admitted to Good Hope Hospital with a urine infection and pneumonia. After 5 days she appeared to be getting better, although she was still very poorly. Her Blood Pressure, Heart rate and oxygen levels were all under control.

We left her on the Saturday night in good spirits and went home. We were called at 6.40 am to be told that she had taken a turn for the worse and could we come to the hospital. When we got there we were left for quite a while until a nurse came and told her that my mother had died. She was sat up in bed at 6.00 am and at 6.15 am a nurse administered her Potassium, she died apparently sometime between 6.25 and 6.40 am after suffering a cardiac arrest.

They said a "mistake" had been made whilst administering this dangerous drug. It has been confirmed by the hospital that no 2nd nurse checked the administration, the pump was not faulty and my mother had 5 hours potassium in 30 minutes. I have had an apology from the Trust and they are carrying out a Serious Untoward Incident investigation. We are waiting for the Inquest.

I also asked the hospital to provide me with a copy of their Intravenous Potassium policy, which they have done. This clearly states that 2 nurses or 1 nurse and a doctor should check and sign when potassium is administered. There is a Patient Safety Alert that also says the same.

So my question is Why did this not happen? It was just before the night shift was ending, my Mum was in the High Dependency Unit.

I have met some of the most loveliest people through this tragedy and together we hope to raise the profile and let everyone know what goes on.

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Responses

Response from Hospital Director, Heart of England NHS Foundation Trust

We would like to apologise again to you and your family for the error which was made.

We are carrying out a full internal investigation which will be shared in full with the family and the Coroner. The aim of the investigation is to understand how and why this error occurred and what lessons can be learnt locally and nationally.

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