· I heard evidence that when Ms GARLAND was on the Cardiac High Dependency Unit ‘HDU’ (part of the Intensive Care Unit) she was receiving intravenous antibiotics
· When she then transferred from HDU to the Cardiac Ward there was a transcription error, and these antibiotics were accidentally omitted from the list of medications that she should be given on the new ward
· As a result Ms GARLAND’s antibiotics were discontinued accidentally.
· I heard evidence from an ICU Consultant (who I found to be both a reliable and an impressive witness), who told me, among other things, that:
– “… Transcription errors have always been a problem…” the ideal way to get rid of them would be to have a system [in the rest of the hospital] that speaks to ours
– The ICU retains lists of its patients’ medication on a computerised/electronic system
– The rest of the wards in the hospital do not operate the same system
– The available systems do not speak to each other (to put it in somewhat colloquial terms)
– Efforts to address that problem have proved fruitless
– As a result, every time an inpatient moves from ICU to another department in the hospital, an appropriately qualified member of staff has to physically transcribe that patient’s medication list
– With (for instance) 10 patients moving per day, 15-20 medications per patient, and multiple elements for each medication (name; dose; timing; indication; start date; signature etc.), “at a conservative estimate 1,500 to 2,000 elements [are transcribed] daily”
(Coroner’s comment: for obvious reasons this creates enormous potential for human error)