Intended for healthcare professionals


Deaths from medicines: lessons from coroners’ reports are too easily lost, review finds

BMJ 2018; 363 doi: (Published 12 October 2018) Cite this as: BMJ 2018;363:k4322

Re: Deaths from medicines: lessons from coroners’ reports are too easily lost, review finds. Some more lessons too.

Prof Ferner and colleagues tell us how forgetful the system is. Besides HM’s Coroners, there are numerous other points in the patients’ treatment where patients may come to harm - fatal or non-fatal..

Now that clinical commissioning groups are telling the public to stock up their cupboards with analgesics ( such as paracetamol) people may well take medicines and forget to tell their doctor or the pharmacist what they have swallowed. NICE is currently contemplating advising age public to use “ household remedies “ when they develop flue like symptoms. In this globalised Britain, household remedies are not confined to Lemsip and honey and Fisherman’s Friend. Of course there is camomille tea ( reputedly non-toxic) . But, might I request NICE to publish a list of the harmless remedies that we the public could keep in our cupboards?

It used to be said that the GPs’ errors come to light in the hospital medical wards, the physicians’ errors are picked up by the surgeons, the surgeon’s errors are picked up by the Morbid Anatomist on autopsy.
Inevitably there is a tendency to gloss over the errors. Dog does not bite dog.
But, would it not be possible, in EVERY HOSPITAL, for a clinicopathological meeting to take place every week where “ lessons may be learnt” from errors? Reputedly the NHS is short of staff and Flu is coming. Harassed staff will be more likely to make mistakes, some fatal, some less serious.
Would the BMJ consider publishing, anonymised brief accounts of pharmacologica errors committed?
Lastly but more importantlt, , could the drug manufacturers consider paying a little fee to every doctor who reports adverse reactions to drugs prescribed or taken by the patient without prescription? It should not break their bank. But, the doctors may be “ incentivised” to look out for adverse reactions - even when the data sheet has not listed them.

Competing interests: No competing interests

13 October 2018
JK Anand
Retired doctor
Free spirit