Patient at Northampton psychiatric hospital died after nurse muddled medication, panel hears

Ms Gwenamo was directed to work at an unfamiliar ward at Berrywood Hospital, where she mixed up two patients' medication.
Ms Gwenamo was directed to work at an unfamiliar ward at Berrywood Hospital, where she mixed up two patients' medication.
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A nurse who botched a medication round at a Northampton hospital that led to the death of a patient has been let off with a caution.

While on duty at an unfamiliar ward at Berrywood Hospital, in Duston, Misodzi Gwenamo gave a large dose of medication to the wrong patient.

The ward then failed to provide sufficient emergency care as the patient's condition worsened until she died.

Gwenamo admitted all charges of misconduct at a Nursing and Midwifery Council disciplinary hearing on July 24.

The panel heard how on August 3, 2014, Gwenamo arrived to work at her normal psychiatric ward but was told to go to a smaller unit due to staff shortages.

While on duty, Ms Gwenamo confused two patients during the nighttime medication round and administered a large dose of the drug Clozapine to the wrong person.

She soon realised her error when the correct patient approached her for her medication. Gwenamo informed her superiors of the mistake - but the duty doctor only ordered for the affected patient to be sedated and monitored.

The report said: "Gwenamo was panicked about her error, but proceeded to report her drug error to the night nurse manager.

"Neither the night nurse manager nor the duty doctor recognised the seriousness of this incident.

"Further, neither the night nurse manager nor duty doctor attended the patient that night nor contacted [the hospital] at their own discretion enquiring about the well-being of Patient A."

As the patient's condition grew worse and worse, Gwenamo again reported her concerns to the duty doctor. She called for an ambulance and resuscitation was carried out, but sadly the patient was pronounced dead at 5.13am.

The report said: "Ms Gwenamo has consistently accepted responsibility and shown significant remorse for her actions.

"In her own words, Ms Gwenamo says she remains very troubled and distressed by the incident and a not a day passes where she does not think of the incident and the family of Patient A.

"The panel is of the view that the misconduct involved was serious and did result in the death of a patient."

A caution order for a three-year period was imposed to "mark the seriousness of Ms Gwenamo’s misconduct, whilst also maintaining the public interest in allowing a skilled nurse to practise."

A spokesman for Berrywood Hospital said: "This was a very sad incident for all involved and we again offer our sincere condolences to the family. Following this incident in 2014 we have worked collaboratively with the staff involved and with the Nursing & Midwifery Council.

"We immediately took steps to address the issues raised, undertake a full investigation and take appropriate actions. These included specific work with staff, training and learning across the Trust. We are satisfied that the NMC report supports our decisions and the appropriateness of our processes. NHFT has safety and quality of service as our highest priority."