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in January 2017 I was admitted to
hospital with chest pain it was
ultimately diagnosed as pneumonia and
everything went well to begin with
except that I didn't notice I was
admitted without a wristband to identify
me
I didn't notice and nor did the staff
and despite going through two wards and
a series of interventions with drugs and
intravenous drugs and moving Ward nobody
noticed that I didn't have an
identification wristband I ultimately
swapped identity with a patient in the
next bed and was given incorrect
medication this made me very ill the
first drug made me violently sick and
pass out I said to the nurse where are
my Parkinson's drugs which are mustn't
stop taking and she said but but you
haven't got Parkinson's and I thought
wow they think I look good but in fact
they thought I was somebody else and
when she realized that I did have
Parkinson's and I said and look I
haven't got a wristband either she went
rather white and she went and got me a
wristband and my Parkinson's drugs were
written up for me but it took about ten
hours before I was allowed to take them
they reacted with another of the drugs
to give me wild hallucinations and every
time I shut my eyes there was a great
big hole opened up on the ceiling full
of snakes and lizards all different
colors moving around and I felt so ill
and I think ultimately it was decided
this was caused by my Parkinson's drugs
interacting with some other incorrect
drugs that I've been given well on
leaving hospital I needed to know what
these drugs were that had taken and I've
got no information from the staff while
I was there so I made an approach
through pals the patient liaison service
to try and informally get the
information because I didn't want to
complain you
to getting excellent treatment from the
NHS stuff they're hard-working and hard
pressed and it seems ungrateful to
complain I have family members who work
for the NHS whole host of reasons why I
didn't want to complain but I had an
informal meeting with a consultant and a
matron who'd been investigating my case
and they wrote to my doctor implying
that I was a rather confused old lady
that had a temperature and therefore
just imagined the whole thing
actually I was only recently retired
from being a company director I was
qualified chartered chemist I've been
traveling the world as a consultant up
until just 10 months before this and I
may have looked like a rather dejected
granny when I was feeling very ill but
in fact I had the the tools at my
disposal to investigate chemical errors
I was a chemist I made made tablets
though I just couldn't leave it at that
I was hopping mad I was I had to make a
complaint at that point in the end we
had two complaint meetings the first one
I was sent the transcript and it all
looked very good but there were still
some questions in my mind I didn't have
the full story at that point and we had
a second meeting which filled in some of
the blanks that been a good
investigation from the pharmacy which
indicated what potentially I had taken
but I have still not seen any final
report about the incident the one thing
it did say is that one nurse had been
blamed and was being given retraining it
was a system error at least 10 people
missed the opportunity to see that I
didn't have a wristband and I was given
drugs while I was unconscious and people
signed for it how did they know who I
was people will not come forward if
they're going to be blamed for reporting
errors and that just discourages people
from being open and honest about
complaints I think there are three key
things for the NHS to learn from
experience first of all for the nursing
staff listen to the patient this would
not have happened if I'd been listened
to
secondly the managers need to make sure
that staff are trained and know that
they can report an error without being
blamed they if they know that that is
allowed and that is encouraged then they
will be honest and open and finally for
the policymakers make sure that this
kind of problem has to be reported
because if we don't report it the
problem is invisible and you have to
first admit to a problem before you can
solve it
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you
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