A CORONER has ruled an open verdict into the death of a Barrow man who died hours after being the wrong drug by an intensive care doctor.
Arnold Harper, 56, was being treated in hospital for 'non life-threatening injuries' after crashing his van into a sea wall, and was expected to make a full recovery.
But when he became agitated as medics tried to “log roll” him to put an X-ray plate under his back, Dr Pieter DuPreez reached out and activated the wrong syringe, inducing a cardiac arrest.
However, after experts failed to agree over a certain cause of death, coroner Dr James Adeley said he did not have the required standard of proof to record anything other than an open verdict.
During the four-day inquest at Preston Coroner's court, Dr DuPreez apologised to members of Mr Harper's family after admitted picking up the Noradrenaline pump instead of the sedative Alfentanil.
Dr DuPreez said: "I looked at the syringe pumps and I went for the syringe which I felt was Alfentanil.
"I can't remember exactly why at the time I decided that was it. Alfentanil has a sky blue label and Noradrenalinne is purple.
"It all happened quite quickly. He needed sedative quickly, I reached for what I thought was Alfentanil.
"I instinctively gave what I thought was the right one.
"I didn't want to upset you more. I didn't want to say it had been done in error to cause you any more upset and I am terribly sorry about that."
The inquest heard Mr Harper was airlifted to Royal Preston Hospital following the crash on the A5087 coast road in Barrow on November 10, 2013.
He had been driving a van which he was touring the country in after selling his home.
It was discovered he had broken his right leg, breastbone, collar bone and fractured three vertebrae. He also had a head injury and had been drifting in and out of consciousness.
But consultant orthopaedic surgeon Manoj Khatri, who treated him during a five-and-a-half hour operation, told the inquest: "The only significant injuries were fractures. I would not have expected him to die in the next 24 or 48 hours because of those injuries."
When Mr Harper, a retired courier from Thwaite Street, Barrow-in Furness, Cumbria, was transferred to the hospital’s Intensive Treatment Unit (ITU) he was conscious and talking.
He was expected to survive but hours after being administered the wrong injection he was dead.
South African Dr DuPreez, who has practised in Britain for 15 years, admitted giving the retired courier a powerful dose of adrenalin instead of a sedative following five-and- a-half hours of surgery.
The patients blood pressure and heart-rate rocketed and, despite efforts to revive him, he died of a cardiac arrest shortly after.
Near to tears, Dr DuPreez faced members of Mr Harper’s family at an inquest in Preston and said: "I am terribly sorry, I made a mistake.
"Whether that had any impact or not I don't know. But, regardless, I am sorry for your loss."
The inquest heard the drug was one of four different medications in a bank of syringe drivers at Mr Harper’s bedside in the hospital's ITU suite.
Two were sedatives, one was for pain relief and the fourth, Noradrenaline, was to bring his blood pressure up following trauma.
Pathologist Dr Alison Armour gave evidence to the court which concluded that she didn’t know why Arnold Harper died but that she believed he didn’t die of natural causes and didn’t die due to his injuries sustained on the road traffic collision.
Dr Armour said: “In my opinion there was no underlying natural disease to account for this man’s death.
“This man did not die as a result of his injuries that he sustained at the time of the accident and I don’t know why he died when he did.”
However her evidence conflicted that of expert consultant anaesthetist Professor Charles Deakin’s who stated that the drug errors neither caused nor contributed to the death either in the form of the maladministration of noradrenaline or the failure to recommence the adrenaline infusion when the BP dropped.
When discussing why Dr DuPreez may have failed to note any of the coloured labels before injecting Mr Harper with the wrong drug, Professor Deakin described the case as “severely unacceptable”.
Dr Adeley did however conclude that the treating orthopaedic surgeon, IT consultant and consultant anaesthetist for the operation all stated that prioer to the drug error Arnold Harper was not expected to die immediately.
A cause of death was recorded as unascertained.
Offering his condolences to Mr Harper's family, Dr Adeley said: "In conclusion due to the deficits in evidence and the conflicting views of experts I do not find that the elements of the various conclusions are made out or not made out to the relevant standard of proof as I’ve set out.
"It's sadly one of those where no-one agrees on the cause of death.
“Consequently, I will return an open conclusion for this inquest and the cause of death is unascertained.”
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