NHS device scandal may have killed Great Yarmouth man
PUBLISHED: 09:01 20 August 2018 | UPDATED: 16:59 20 August 2018
A Great Yarmouth man was one of at least four patients who may have died when the NHS continued using syringe drivers over which safety concerns had been raised.
Michael Shuckford, 79, died on August 2, 2011.
The retired butcher was terminally ill but was given a 24-hour dose of diamorphine in 12 hours at the James Paget University Hospital in Gorleston using a syringe driver, a battery-operated device which delivers medication automatically.
Now, an investigation by the Sunday Times has revealed the devices were permitted to be used until 2015, despite warnings over the risk of fatalities from user error from 2010.
The Sunday Times said up to nine people died because Britain continued to use the syringe pumps when other countries had chosen to stop using them.
Rather than issue an immediate recall, in 2010 health bosses opted for a five-year transition period to phase out the devices.
The paper reported that a briefing note sent to NHS chief executives advised: “Longer periods of transition (for example five years) will reduce cost... However, prolonging the use of both types of devices increases the risk of confusion and therefore error.”
MORE: Hospital trust urged to conduct investigation after Michael Shuckford’s death
At their height, tens of thousands of Graseby MS26 and Graseby MS16A syringe pumps were in use across the NHS and they were considered an “essential component of palliative care”.
However, doctors raised concerns after cases emerged of patients receiving dangerous over-infusions of drugs caused by confusion over how the models operated.
In 2007, Australia and New Zealand banned imports of the syringe pumps, although the NHS only began its transition three years later.
In June, an NHS whistleblower told the Times that the syringe pumps’ use could have resulted in widespread premature deaths among elderly patients over the years.
One of those could have been Mr Shuckford.
Coroner William Armstrong said at the time Mr Shuckford died from natural causes – as he had a combination of serious illnesses including a heart condition and renal failure – but the infusion of medication through a syringe driver was recorded as a contributory factor.
Mr Armstrong raised concerns six years ago that while the alarm had been raised nationally in 2010 about the syringe driver, the trust had until 2015 to implement changes to replace it and reduce the risk of it happening again.
At the time Sarah Plume, matron of the ward where Mr Shuckford died, apologised on behalf of James Paget Hospital and accepted that the inquest had revealed evidence of confusion and misunderstandings.
Yesterday Mr Shuckford’s son David told the Sunday Times: “Mistakes like that just shouldn’t happen. It’s about people’s lives at the end of the day, so it shouldn’t be down to cost. If they’re potentially dangerous, they shouldn’t be using them.”
The hospital said it launched a “comprehensive investigation” following Mr Shuckford’s death and had replaced all Graseby MS 16A and MS 26 syringe pumps by the end of May 2012.
Director of nursing at the Julia Hunt said “A new syringe driver, which had a number of additional safety features, was brought in and a programme of training was given to ensure staff were confident in the use of the new equipment.”
The NHS said on Sunday that a patient safety alert issued in 2010 urged all organisations to phase out the devices “as soon as possible but no later than by 2015”.
Aidan Fowler, national director for patient safety at NHS Improvement, said: “This deadline was set to avoid the risk of patients going without access to this important source of pain relief due to the expected time needed to source an acceptable alternative device and ensure healthcare staff were appropriately trained in how to administer it.”
He said that the NHS has been sent “clear messages that the use of the old-style Graseby syringe devices should not continue under any circumstance”.
“Currently, we do not believe the older style devices are in use anywhere within the NHS. If there are instances, we encourage NHS trusts to notify us so that we can understand why,” Mr Fowler said.