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Man died after prescription error


A man died because he was given the wrong prescription after a breakdown in communication at the University Hospital of Wales, Cardiff, an inquest has heard.

After Paul Smith, 46, had a stent placed in an artery he was told to take the clot-busting medication clopidogrel for just one month instead of the 12 that should have been specified.

Four weeks after he stopped taking the drug he was rushed back to hospital with a blood clot in his heart. He was operated on, but died of complications the next day.

Mr Smith, of Cathedral View, Cardiff, had stopped taking the medication as directed on the medication card he was given when he was allowed home.

Returning a narrative verdict, which set out the facts of the case, Cardiff Coroner Mary Hassell said: “Mr Smith was given the wrong instructions because of a breakdown in communication between the specialist registrar and the staff nurse.

“The correct message was neither correctly relayed, nor clearly understood.”

Evidence was given to the inquest of changes that had been made to procedures at the hospital since Mr Smith’s death.

These include prescriptions being written out in full, in block capitals, with no abbreviations, before they are given to a nurse to fill out the green medication card.

Electronic prescriptions are also being considered.

A review is also under way among cardiologists at the hospital to get a uniform agreement on the usage of clopidogrel.

Copyright Press Association 2009

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