Hospital overdose case

Press, 13 July 1984, Page 9

Hospital overdose case

PA Hamilton The parents of Vika Abbott, the victim of a hospital morphine overdose, have gone" to the Accident Compensation Commission over their daughter’s death. Her father, Mr Geoffrey Abott, said he, his wife, Tupou, and their son, aged 19, were glad the controversy surrounding the death was settled.

He said they had approached the commission before the inquest concluded on Tuesday — “that is all we have to say about it.”

Told the outcome of the inquest, Mrs Abbott said she was unsure how she felt about it. “I still feel I did not want it to go on this way,” she said.

Mrs Abbott, a Tongan, and her Australian husband adopted Vika from Tonga when she was three months old and brought her to New Zealand. She was their only daughter. Police yesterday confirmed that no charges would be laid over the death of Miss Abbott in Waikato Hospital. The acting head of the C. 1.8. in Hamilton, Inspector Rex Miller, said the police had conducted a long and thorough inquiry into the death and were prepared to accept the finding of the Hamilton Coroner, Mr John Webb, that further police investigation was unnecessary

Factors contributing to the accidental overdose, identified on Tuesday by the Coroner and hospital staff, were:

© A clinical assistant was identified as “doctor” on a name badge, giving staff the impression that that person was more qualified than she was.

0 The patient’s excessive weight made drug prescription more complex. © A drug dose was misheard in a telephone conversation. © Doctors and other staff had worked long hours with little sleep. © Insufficient monitoring of the patient’s condition after such a large dose of narcotics could have contributed to her death.

The police investigation into the 1982 death was spread over 15 months and included inquiries in Australia, where two hospital staff involved in the overdose now live.

Mr Miller said the inquiry file had been studied by legal and medical experts and the police were satisfied that the case did not warrant criminal charges being pursued. He said the file had been sent to Police National Headquarters and examined by the legal section there for criminal negligence.

“I do not believe there is any reason why the police should pursue their investigations any further,” said

Mr Webb at the conclusion of an inquest into the death of Miss Abbott. Miss Abbott was 28 when she died in October, 1982, after being given 50 mg of morphine. The inquest, begun in February, was adjourned twice while the police sought evidence from Dr Marion Myree Marsh in Australia. Mr Webb said the fact that Dr Marsh, a clinical assistant at the time, wore a badge describing her as “doctor” was one of several factors contributing to the fatal overdose.

Mr David Wilson, the lawyer representing Dr Marsh, said claims that she was at fault in administering the fatal dose were unfair and not based on evidence. Mr Wilson said Dr Marsh had been aged 22 and working as a clinical assistant at Waikato Hospital for only nine days when the accident occurred. The Coroner heard that Dr Marsh was a final-year medical student at the University of New South Wales and had come to New Zealand to gain practical medical experience. “It is quite evident that Miss Marsh was the least experienced of the people involved in this incident,” her lawyer said. “To date, it appears everybody is saying she was at fault. I believe that is un-

fair, unkind, and not based on the evidence.”

At the February court sitting, Charge Nurse Christine Kane said she twice questioned the dose, but Miss Marsh assured her it was the dose stated by a hospital registrar, Dr Julian Egerton-Vernon, and so she gave it to the patient. Dr Egerton-Vernon had later told the police he had advised a 15mg dose of morphine for Miss Abbott’s ankle pain. He had spoken to Miss Marsh by telephone. In a statement, Miss Marsh said she did not prescribe the morphine, but had simply passed on Dr Egerton-vernon’s prescription for a nurse to administer.

The Coroner found Miss Abbott died from acute poisoning resulting from accidental administration of morphine.

He said it was obvious that Dr Egerton-Vernon thought Miss Marsh had more power and experience than she did, particularly in prescribing drugs. It was clear that she had mistaken “15mg” for “50mg” in the conversation, said the Coroner.