DWYER: NURSE STRUCK OFF OVER DRUG MISTAKE
A nurse who almost gave a patient a lethal dose of insulin, then failed to immediately report the blunder to a senior member of staff has been struck off.
Rachel Dwyer (nee West), 30, used the wrong type of syringe and drew 10 times the prescribed amount of the drug, used to treat diabetes, the Nursing and Midwifery Council heard.
The patient, known as Miss A, had to bring the ‘grave’ error to the attention of Dwyer, who was working as a staff nurse on the general ward at Addenbrooke’s Hospital in Cambridge.
But red-faced Dwyer kept quiet about the blunder, on July 7, 2008, and it was only six hours after, when Miss A informed senior staff nurse, Sarah Cottee, that the incident came to light.
Miss A, herself an experienced nurse, told the central London hearing that, if she had not noticed Dwyer’s mistake, she could have been given a ‘potential fatal dose’.
She said: ‘Rachel came into my bay with a cardboard tray, with the insulin already drawn in a syringe.
‘I noticed it looked like a larger syringe and had 60 units of insulin.
‘When I pointed out it was the wrong dose, she went red and it was as if she didn’t realise she’d got it wrong. But she agreed with my judgement and we expelled the excess insulin.
‘It didn’t hit me until afterwards but then I thought, ‘that could have been really bad’.
‘I was quite shaken up and it took me a long time to trust other nurses again, I would watch them closely.’
Mrs Cottee told the hearing that Dwyer made no attempts to talk to her or explain the situation, despite the fact they were working together for about six hours.
She added: ‘It is policy that all staff should report incidents promptly and I asked her to fill in an incident form.
‘She was quite defensive and reluctant to do this and I felt quite uncomfortable.’
Cambridge University Hospitals NHS Foundation Trust then referred the matter to the NMC.
Dwyer, who registered as a nurse in 2003, admitted using the wrong type of syringe and drawing the incorrect amount of insulin.
The panel found her guilty of intending to administer or oversee the administration of insulin, and failing to immediately report the incident to a senior member of staff, which she denied.
Dwyer, who did not attend the hearing, was struck off after her fitness to practice impaired.
Panel chair, Catherine Duthie, said: ‘This could have had life threatening consequences for the patient.
‘The panel considered the incident to be extremely serious.
‘Dwyer broke the confidence a patient should have in a nurse, took no steps to report the incident and, in not doing this, breached the standards expected by a nurse.
‘The consequences for Miss A were potentially grave.’
ENDS
