Sheffield nurse struck off after drugs blunder contributed to patient’s death

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A Sheffield nurse has been struck off after giving a patient more than quadruple his dosage of anti-psychotic drugs a day before he was found dead in his bath.

James Buck was a mental health nurse on Sheffield Health and Social Care’s Maple Ward at the time of the blunder on November 23, 2012.

The patient was found dead at his home, partially submerged in his bathtub, the next day, the Nursing and Midwifery Council heard.

The man – known only as Patient A – had been detained under the mental health act but was due to go on three days’ leave from the ward in preparation for a provisional discharge.

A three-day dose of the anti-psychotic drug Olanzapine had been prepared for him, along with a further 14 days-worth if doctors decided he was ready to be discharged.

But Buck accidentally handed the unwell man the 14-day dosage instead of the three-day dosage, then failed to record the quantity he had handed over in the drugs book.

The patient was found dead at his home the day after being discharged.

A jury inquest in found his death was caused by drowning, with Olanzapine toxicity recorded as a secondary cause.

Two empty packets of Olanzapine were found in the patient’s kitchen and an empty box in his bedroom, but no suicide note.

In their verdict, the jury found Patient A’s assessment and treatment at Maple Ward was not adequate due to ‘poor record keeping, failure to keep adequate records [and] poor communication with staff, family and friends.

It stated there was a ‘failure to follow the trust’s policies on dispensing drugs, lack of clinical management and leadership, risk assessments [were] not done and lack of overall care’.

The jury further found that Patient A’s death was contributed to by neglect and that there was a ‘failure to communicate and listen to family and friends, particularly on November 23’.

Buck, who was not present or represented, admitted handing over the wrong dose of Olanzapine and failing to note the quantity he had handed out in the drugs book.

He also admitted that his mistake had given Patient A the chance to overdose and that his actions amounted to misconduct.

An internal investigation into the patient’s death found that Buck had not checked or signed for the medication against the prescription.

It found that Buck hadn’t ‘paid due care and attention to the task in hand’.

Buck told investigators that he hadn’t acted in accordance with policy because his working memory had ‘become overload’.

He added it was not uncommon for discharge medication to be given in advance of a patient formally being discharged.

He also stated that he couldn’t find the three day dose of medication that had been prepared, but admitted he should have contacted a superior to get a new prescription made up.

Buck said the ward had been really busy at the time of his mistake, and that he had also been experiencing low blood sugar and poor sleep which may have impaired his judgement.

He has not worked as a nurse since being dismissed from the Maple Ward, and told the NMC in a letter ‘I have no plan, desire, or indeed ability to practice as a nurse. My ability to do so remains impaired. Having reached the age of 65, my plan is to retire from employment completely no later than June 9, 2016.’

Since his dismissal, Beck has been working as a support worker at Forest Lodge – a unit focusing on the rehabilitation of offenders with mental health problems.

Striking him off the register, panel chair Alison Stone said: “The registrant’s failure to follow the trust’s medication policies gave Patient A the opportunity to overdose on Olanzapine which contributed towards his death.”

She added: “Although the registrant cites high workload in mitigation of his actions, it is agreed that regardless of this he should have ensured that he adhered to the trust’s leave medication policy when dispensing these drugs.”

She said it was clear that Buck was remorseful and had repeatedly apologised for his error, but noted he admitted making other medication errors in the past.

Ms Stone said: “The registrant stated that he was busy during the day in question and that he provided the medication because it was the only medication he could locate.

“The registrant accepts that there were long standing flaws in his practice and that he needs significant time to reflect on and learn from his errors.

“In view of the seriousness of the misconduct, a striking off order is the only sanction sufficient to protect the public interest and maintain confidence in the nursing profession and the NMC as its regulator.”

Buck was given 28 days to appeal the panel’s decision.

Kevan Taylor, Chief Executive of Sheffield Health and Social Care NHS Foundation Trust, said: “We would like to offer our sincere condolences to the family of Patient A.

“We recognise the very serious nature of this incident. We conducted a thorough investigation in line with our policies and procedures and ensured that appropriate action was taken. I can confirm that Mr Buck is no longer working as a nurse within the Trust.”