Drugs were dispensed at University Hospital Limerick for patient who had died 12 hours earlier

The unpublished report on the death of Martin Abbott (65) found the medicines were dispensed in his name even though he had not been prescribed them and these continued to be prescribed even after he had died.

Mr Abbott, from Shannon, Co Clare, fell off a trolley in a cubicle in the crowded emergency ward in December 2019. He was dead on the floor for more than an hour before he was found.

The Systems Analysis Review (SAR) of his death — disclosed in the Sunday Independent last weekend — reported “major avoidable errors” in his care and charted how his deteriorating condition went undetected.

However the unpublished report singled out “severe” overcrowding in the emergency department as the “fundamental” cause of Mr Abbott’s death.

Further details from the unpublished report reveal how the review team was unable to establish what drugs Mr Abbott had been prescribed.

Not only was the nurses’ handwritten record of his medication record missing, but the inaccurate automated record showed drugs being dispensed in the names of patients who had not been prescribed the medications.

The review suggested that while the issue was not a factor Mr Abbott’s death, there was a risk to patients of being administered the wrong medicine.

The problem came to light when the review team asked for a record of Mr Abbott’s medications.

Drugs are dispensed from two dispensing cabinets in the hospital’s emergency department, the report said.

An automated report from the two dispensing cabinets should have produced an accurate list of drugs that were booked out in his name.

However, a senior clinical pharmacist emailed the review team, to say the “[medication] list is inaccurate in that it contains medications booked out to Patient Y [Mr Abbott] that he did not receive”.

The review team found that 39 drugs were booked out in Martin Abbott’s name over two days — with one drug dispensed 12 hours after he died.

Only 24 of the 39 drugs “could possibly have been” for Mr Abbott, the review team’s report said.

This meant the dispensing record — the only other record of the drugs aside from Mr Abbott’s drug Kardex — was unreliable and the review team couldn’t count on it to establish which drugs he received.

In the email to the review team, the pharmacist suggested that the problem may have been caused by patients presenting in the emergency department, but whose names are not entered on the automated dispensing cabinets.

The email explained that staff log on to the dispensing cabinet with a fingerprint, select the patient and the drugs required, with a record of the medication and the transaction stored on the system.

The review team said the standard operating procedure by staff needed to be “urgently” addressed to “ensure medication safety”.

It was found that while these deficits did not contribute to Mr Abbott’s death, the risk to patients of being administered the incorrect medicine were so great that training should be implemented within three months.

University Hospital Limerick, which serves a large catchment area in the mid-West, has struggled to deal with consistent overcrowding in its emergency department. Inquiries are at various stages into the deaths of three other patients at the hospital since Mr Abbott died.

An inquest 10 days ago attributed his death to medical misadventure. ULH group has apologised for the failings in his care.

Health Minister Stephen Donnelly announced a range of new measures to tackle the crowding problem following a crisis visit to UHL last week.

These include 24/7 opening hours to be extended to three acute medical units in Nenagh, Ennis and St Johns, a 50-bed nursing unit in Nenagh to be used as a step-down facility for Limerick for one year until the first of two 96-bed blocks opens, GP and advanced nurse practitioners providing “on-the-door” services to alleviate overcrowding and safe staffing for all wards.

He said he also wanted consultants to be more visible in the ED.

Speaking about Mr Abbott’s case, he said the unpublished report “catalogued a series of failures” in his care. He “also called out the fact that solutions to overcrowding which have worked in other hospitals have yet to be seen here (in UHL)”.