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| NEWS | BY KIM JANSSEN and ANDREW WALKER |
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Graphic designer Ian Smith, 39, suffered a heart attack at the Royal Free Hospital in Hampstead within five minutes of Dr Adrian England injecting him with a massive dose of dopamine, a drug used to open up the arteries that serve the kidneys, St Pancras Coroner’s Court heard. Dr England, a consultant anaesthetist, had meant to administer a pain-killer, pethidine, to the recovering kidney transplant patient. Colleagues spent nearly an hour trying to re-establish a heartbeat without success after he used the wrong syringe. But coroner Dr Andrew Reid congratulated Dr England for “saying what he did so quickly and having the courage and candour to deal with the deceased’s family”. Mr Smith’s father, Guy, had earlier explained that his son had suffered from a rare kidney and heart condition, known as Fabry’s disease, from childhood, which meant he had to undergo painful treatment regularly. “He heard there was a kidney available for transplant and he was so pleased – it looked like the end to all his trauma,” Mr Smith said. “After the operation I came down to the recovery room and saw my ex-wife, Ian’s mother Yvonne, in a terrible state. There was some panic going on in the recovery room and we left to a waiting room. “Eventually, four doctors came in. They locked the door behind them. “Dr England explained he had administered the wrong drug. Ian had complained of pain and he had given him the wrong drug and he had died as a result of it. “Ian’s mother said ‘you poor man’ and kept repeating it. “I made a comment of which I’m not proud and stormed out of the room.” Dr England, who was interviewed by police, realised his mistake 30 minutes after Mr Smith began to have a fit. He said: “When I said I was injecting pethidine I was absolutely certain it was pethidine. But when I reviewed the injection it seemed entirely plausible that a drug error had occurred. “The syringes were identical. They both had standard yellow labels. The dopamine injector had a red label on the back but I was not aware of it.” Mr Smith’s mother, Yvonne, said: “I walked into the ward and Ian was calling ‘Mum, mum, have I got a new kidney?’ and I said ‘Yes, you have’. “He said ‘I love you mum’ and then said ‘pain, pain’. Dr England said ‘You don’t have to be in pain, I’ll give you some pethidine. It was only a short space of time between the drug he thought was pethidine being administered until Ian began fitting violently. I knew at that point he was dying.” A post-mortem report after the death of Mr Smith, from New Southgate, north London, on February 23, 2001 showed his diseased heart was twice the normal size, meaning he was at far greater risk of a heart attack than the two per cent assessment made by doctors before the transplant, forensic pathologist Nathaniel Cary said. But a delay in taking a blood sample after Mr Smith’s death meant it was impossible to judge how much dopamine he was given. The heart attack could have had other causes, he added. Dr Reid recorded a verdict of accidental death, listing both Mr Smith’s long-standing illness and the dopamine overdose as causes. Outside the court, Guy Smith said: “It’s been three years and this is the end, we want to let it rest. The Criminal Prosecution Service decided there was insufficient evidence to prosecute and we’ve had to accept that. The General Medical Council has said it is waiting for the result of this inquest before deciding to have its own hearing.” |
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