A DIABETIC was accidentally given 10 times their normal dose of insulin by a nurse working for Northamptonshire’s mental health trust.
Little about the incident can be made public because the NHS has to preserve patient confidentiality.
However bosses at Northamptonshire Healthcare NHS Foundation Trust revealed in its latest board papers that it has now increased its risk rating after the mistake earlier this year.
Susan Clennett, head of risk and patient safety, in a report to directors, said: “This current risk rating has been reviewed in light of a recent serious incident where there was maladministration of insulin to a patient (10 times the correct dosage).”
An insulin overdose can be very dangerous, even fatal, as the hormone reduces the levels of glucose in the body. Too much can lead to a hypoglycemia attack.
It is understood that the patient was left relatively unharmed but Mrs Clennett said the error “could have” resulted in a serious incident. The report has to be included in board papers after a list of ‘Never Events’ were increased by the Department of Health during early 2011. Bosses said they are now conducting a clinical review of how the dosage could have been so massively misjudged, and will learn lessons from the report.
Meanwhile, elsewhere in the board papers, Healthcare bosses have also maintained the ‘high’ risk rating for ‘potential damage to public confidence because of the results of a report by the Ministry of Justice into two patient deaths.
The annual Rule 43 report – named after the rule whereby coroners can ask an organisation to make changes as a result of a death – named the incidents at St Mary’s Hospital in Kettering in 2011.
Again, patient confidentiality means the NHS will not reveal specific details but it is believed one was that of the death of a 31-year-old man.
His inquest found mental health staff knew he had attempted suicide more than eight times before, but no-one visited him after he cancelled one psychiatric appointment and missed two more.
Mrs Clennett said in the new report, ‘Damage to public confidence in delivery of safe service’: “There is the potential for media coverage on this. Potential impact on these to the organisation is not viewed as catastrophic if risks occurred.”