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Doctor pressure at Newhaven Rehabilitation Centre fatal for patient
A doctor who claims he was forced to carry out “five hours work in two hours” failed to clearly mark how often a cancer-sufferer should receive incredibly toxic medication – and the patient died of an overdose.
Dr Hassan Twins completed a discharge sheet for the 90-year-old patient on leaving the Newhaven Rehabilitation Centre but failed to mark clearly how frequently cyclophosphamide should be taken.
As a consequence it was subsequently dispensed daily, not weekly, as it should have been.
Just over a month after he was discharged from the centre the man was admitted to the Royal Sussex County Hospital in Brighton where he died.
The incident took place in 2010 but Dr Twins has only just been found guilty of misconduct and the details of the case revealed.
A Medical Practitioners’ Tribunal Service (MPTS) was told that Dr Twins, based in Littlehampton, was allowed to keep on practising despite being guilty of the blunder. The MPTS said a system of “checks and balances” which should have been put in place failed.
Neil Usher, representing Dr Twins, said he had been under immense pressure at the time of the incident in March 2010.
The MPTS report said: “Mr Usher submitted that the errors you made took place in the context of pressure of time and a far from ideal working environment.
“The panel heard evidence that the centre was busy and described as chaotic and that you did not have an office or protected time in which to complete paperwork.
“You stated that in order to complete all your tasks conscientiously you would have required at least five hours rather than the contracted two hours for which you were employed.”
Chief operating officer of Sussex Community NHS Trust Richard Curtin said: “We were one of the NHS organisations involved in the care of a patient who died in 2010 as a result of a medication error, and in this way our first thoughts should always be with the patient’s family, and again we express our apologies and condolences.
“The coroner concluded that a number of individual and organisational errors, omissions, system failures and missed opportunities all combined and culminated in the patient’s death.
“As the investigation into the case confirmed, there were times when the medication error could have been avoided, identified and put right, but these opportunities were missed by various organisations involved, and we are sorry for our part in this failure.
“Since this event we have overhauled our systems, including our discharge documentation, to ensure we reduce the risk and impact of error to a minimum.
“We strive always to ensure that our staff and processes all work together to ensure we deliver the best possible care to all our patients all the time.”
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