The GP prescribed Len morphine sulfate oral solution, which has a concentration of 10mg in 5ml, at a dose of 1.25ml to 2.5ml (which equates to 2.5mg to 5mg per dose) to be taken up to every 4 hours when required. Len again contacted his GP with ongoing breathlessness and pain. Len’s family noticed that over the next 2 weeks he became quieter and less active. However, after returning home Len found that the lidocaine pain relief patches he was given irritated his skin and he stopped using them. He was assessed by medical staff who diagnosed a suspected rib fracture. Len was taken to the emergency department at his local hospital. Len’s family later called an ambulance because Len was very breathless and in pain.
At that appointment, the GP ruled out a chest infection, prescribed additional ibuprofen and told Len to continue taking paracetamol. The GP asked Len some questions about his symptoms and offered him a face-to-face appointment that afternoon. Len developed breathing problems so contacted his GP practice by telephone.
Len had previously been diagnosed with Charcot-Marie-Tooth (CMT) disease, which is a progressive disease that affects the nervous system.
Len, who was 89 years old, fell at home and developed pain in the right side of his chest. However, HSIB thought it would be beneficial to publish a shorter investigation report highlighting specific risks which may be associated with morphine sulfate oral liquid and to improve understanding of and engagement with HSIB investigations. The results of the scoping investigation did not meet the criteria for a national investigation. Len’s family referred their concerns to HSIB to consider whether Len’s care highlighted any national safety issues that could be addressed through an HSIB investigation. The reference event concerned Len, who took an accidental overdose of morphine sulfate oral liquid. It also aims to demonstrate the systems-based approach that HSIB uses to identify matters for national investigation, via a scoping investigation into a patient safety incident (referred to here as the ‘reference event’). The aim of this investigation report is to help improve patient safety in relation to the use of oral morphine sulfate solution (a strong pain-relieving medication taken by mouth).
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