Without even looking at me he snarled: ‘Go away, leave me alone. You’re a horrible mum,’” remembers Nicola, 31. “It was so unlike Kieron - who’s normally so happy and affectionate - that it took my breath away.”Later that night, after Nicola had finally coaxed Kieron out of his room, the little boy started sobbing. “He said he wanted to go to sleep and never wake up,” she recalls now, seven months later.
“When I tried to cheer him up, he just repeated it in a very angry tone. I was shocked. Surely a six-year- old boy wasn’t thinking about taking his own life - how could he even know about such things?”
“It was as if a monster had taken over our son,” says Nicola. So she looked for an explanation.
Three years earlier, Kieron had been diagnosed with acute lymphoblastic leukaemia - cancer of the white blood cells, where too many immature white cells are produced.
In November 2004, he began a cycle of low-dose chemotherapy, combined with a steroid called dexamethasone which he took for five days a month.
Dexamethasone is a corticosteroid - it mimics the use of the hormones made by the adrenal glands - and was being used to reduce the number of white blood cells being produced in Kieron’s body.
“During the days he was on the steroids he would always be a bit grumpy and out of sorts,” his mother recalls. “His strange behaviour coincided with the steroids.
“But he’d been taking them for more than two years so although I wondered about it, I couldn’t quite see how, after all that time, they’d suddenly affect him.”
In fact, Kieron had been the victim of a hospital error.
In January this year, his oncologist at St James’s Hospital in Leeds had prescribed him 4.6mg of the drug. This was to be split into two doses, but the pharmacist mistakenly calculated this as
As a result, Kieron was taking 5.6mg per day - over 20 per cent more than he should have done. No one double-checked the dose or spotted the error.
Kieron was overdosing on a very dangerous drug. Known side-effects of steroids include inflammation of the stomach, mood swings and depression.
“In February, Kieron started another five-day course of the steroids,” says Nicola. “This time he was worse. He was telling me he hated us all and then clinging to me like a frightened baby. Normally, he loved school, but now he would sit in class shouting over and over again that he wanted to go home.
“Once, he refused to drink all day. He hit and kicked the other children and would scream at me as I left to take him home. Yet a few days later he was back to his normal, easy-going self.”
That same month, during a hospital visit, Nicola and her partner Simon England, 32, a taxi driver, still shaken by their son’s mood change, asked if Kieron could see a child psychologist.
“We hoped that he might say that it was just childish talk, but he took it very seriously,” says Nicola, who is a care worker for the mentally ill. “He explained that a child of Kieron’s age usually had no concept of suicide, yet his words definitely hinted at suicidal tendencies.
“He told us not to dismiss his fears, but to keep reassuring him that he was safe.”
A few days later Nicola told the oncologist about Kieron’s behaviour. “I said I was frightened about how he changed when he was taking the steroids. She told me to ask the pharmacist to log his reaction to the drug. The pharmacist listened to what I had to say, went away with the prescription and returned a few minutes later.
“She said she was sorry, there had been a mistake and Kieron had been given the wrong dose of steroids for the past two months.
“I was completely numb and left without saying anything.
“Later I became angry. We weren’t dealing with a minor drug for a minor illness. My son was being treated for leukaemia under the care of a world-class cancer team. How could such a sloppy mistake be allowed to happen, and how often was it happening to other people?”
Far too often, if you are one of the families affected.
Earlier this month it was reported that two cancer patients at Birmingham Heartlands Hospital died after they were given an overdose of a drug used to relieve the side-effects of chemotherapy.
Another distressing case was that of Madison Perry, who, aged just two-and-a-half months, was given an overdose of heparin, a blood-thinning drug, at Liverpool’s Alder Hey Hospital after heart surgery in February 2005. The dose had been calculated at 1,500 units, but a nurse read it as 15,000 and Madison died the next day.
Last November Cathy Horton won damages from her GP and Lloyds Pharmacy after she was prescribed steroid tablets eight times the strength of her normal dose. The dispensing chemist didn’t pick up the GP’s mistake and Cathy was admitted to hospital with anxiety and paranoia.
In January, 2001, 18-year-old cancer patient Wayne Jowett had a toxic chemotherapy drug injected into his spine rather than into a vein. Wayne, who was actually in remission from his cancer when the drug was administered, suffered intense pain before lapsing into unconsciousness for nearly a month and dying slowly from a creeping paralysis that eventually stopped his heart.
A study on medication errors published by the Healthcare Commission in 2001 found that around 1,200 patients had died in the previous year due to an error in prescription or an adverse reaction to the drug.
One hospital reported several mistakes, including a cancer patient being prescribed the sleeping tablet Temazepam instead of the anti-cancer drug Tamoxifen; a toxic medicine that was prescribed daily instead of weekly; and a contraceptive steroid prescribed in place of an anti-psychotic drug.
Last year the National Patient Safety Agency reported that about 6.5 per cent of all patients admitted to hospital between January 2005 and June 2006 “experienced medication-related harm”. Although 80 per cent of those resulted in no injury to the patient, there were 92 incidents of severe harm or death.
Most of these errors (around 57 per cent) were due, as in Kieron’s case, to the patient receiving the wrong frequency or strength of dose. Ten per cent affected children under four years old.
The agency admitted the figures were likely to be conservative and did not take account of errors made in community pharmacies.
Jennifer Emerson, a solicitor at the legal firm Irwin Mitchell, which specialises in medical law, believes that cases are greatly under-reported.
“The responsible agencies may say their data gives them an idea of error rates,” she says. “But in the past, researchers have adopted different definitions and categories under which errors are reported, making their findings quite disjointed.
“Their figures also often depend on the voluntary reporting of errors.”
She adds: “People do not always realise they have been the victim of a medication error. They may attribute any unusual effects to their illness, so the error never comes to light.
“Yet it is a significant health issue and the implications for the individual can vary from relatively short-term effects to fatality. Any death is one death too many and a tragedy for the patients and their families.
“Even if you haven’t been severely injured, the repercussions can be very distressing. You may have to undergo hospital investigations, sometimes for many months, all on top of your original illness.”
Pharmacists don’t deny the problem is real or significant - the question is what to do about it.
As Professor Nick Barber, head of the department of practice and policy at The School of Pharmacy, London University, says: “You are dealing with humans, who sometimes make mistakes. The problem for pharmacists is that their mistakes can be very dangerous indeed.”
The family of Elsie Phythian discovered this in February this year. Elsie, 89, from Manchester, was prescribed 100mg of Carbamazepine after falling out of bed and bumping her forehead. She took the drug three times a day as prescribed, but three days later she had a stroke.
Although the prescription read 100mg, Lloyds Pharmacy in Clayton had filled the box with 200mg tablets - so Elsie had been taking double the dose. She went on to spend two months in hospital and now, this previously fit and well grandmother needs 24-hour care.
Lloyds Pharmacy admitted negligence, although not that this was the cause of Elsie’s stroke.
According to Professor Barber, there should be a checking system in every pharmacy. But what happened to this checking system in Kieron’s or Elsie’s case is unclear.
To be fair to pharmacists, most medication errors - nearly 70 per cent - occur when the prescription is handwritten. Computerised prescription in GP surgeries has eliminated this problem in community pharmacies. But in most hospitals, prescriptions are still written by hand.
“In fact, medication errors make up only a small fraction of hospital safety issues,” says Professor Bryony Dean Franklin, of the department of practice and policy at London University’s School of Pharmacy.
“And although the figures may seem frightening, you have to see it in context: around two and a half million prescriptions are written every day.” The vast majority are correct.
In 2005 Professor Dean Franklin published the results of a survey she carried out in the pharmacy department of a Welsh hospital.
Over a two-week period her team found that although there were mistakes made in 2.1 per cent of all prescriptions, only one in 100 of those mistakes made it through to be given to the patient. The rest were picked up in the checking process that should be part of every hospital pharmacy.
However, this means little to those who are affected, and Nicola England is understandably wary of prescriptions after Kieron’s experiences. “When it first happened I became a bit of crusader,” she says. “I told everyone I knew that they should double-check their medication and query it.
“I did question Kieron’s prescription in January because it had been changed. But they said the dose had altered because his weight had changed. They were the professionals, so I accepted it.”
“People do tend to believe that prescriptions are gospel,” says Vanessa Bourne of the Patients Association. “But mistakes can be made, just like any other form of medicine. If you are taking a prescribed drug and you feel strange, then don’t feel that it is ‘just you’. Report your experiences to your pharmacist.”
After Nicola complained about what had happened to her son, the chief executive of the Leeds Teaching Hospitals NHS Trust wrote to say “a full inquiry” had been carried out into the incident. She said procedures had been reviewed to ensure such errors wouldn’t be repeated.
Nicola was also told that there was little likelihood of lasting adverse side-effects affecting Kieron from such a short-term overdose. But she is dissatisfied with the response.
“I can’t help but think what would have happened if there had been a similar mistake with Kieron’s chemotherapy drugs when he was really sick, or if the overdose had been bigger,” she says. “I don’t feel I have had decent answers to those questions.”
Kieron has finished his treatment and is in remission. But if he did have to be readmitted to hospital, Nicola says she would be very wary about what was given to her son.
“I don’t trust the hospital any longer,” she says. “I know that sounds harsh, because they’ve worked hard to care for my son, but if basic mistakes like that can happen, you have to think about what else is going wrong in the system.
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