Wrong drugs tragedy of groom-to-be-Craig

And the family has attacked the decision to allow the nurse involved in the death of 37-year-old bridegroom-to-be Craig Richardson back on the wards at the Royal Bolton Hospital.

Mr Richardson of Kershaw Street, Tyldesley, died of a massive heart attack -- brought on by the medication.

Today hospital chiefs promised to review their policies and introduce extra safeguards.

They have described Mr Richardson's death as a "tragic mistake, a human error."

Bolton Coroner, Mr Aidan Cotter, at an inquest yesterday refused to name or call the nurse to give evidence in an unprecendented move to protect her from "public humiliation or degradation".

But she now awaits to hear from her professional body, the UK Central Care Register, which will judge whether she continues to have a right to practise as a nurse.

Mr Cotter was challenged about refusing to put the nurse in the witness stand by the family's barrister, Joel Donovan QC, who said that the nurse's evidence was in the public interest.

Mr Cotter said: "I am very much aware that this matter is in the interest of the public and must be brought out into the open. I do not believe that there has been one single fact left out of this inquiry.

"I honestly believe that the nurse would not be able to add any more detail. She would break down in tears on the first question."

Mr Cotter said Craig Richardson's death was "an accident" and he was satisfied that the nurse did not commit manslaughter.

The inquiry heard how Mr Richardson suffered a heart attack and died after being given the wrong fluid in an intravenous drip.

Doctors fought for more than two hours to resuscitate Mr Richardson -- who collapsed and died on New Year's Day.

Mr Richardson suffered a massive cardiac arrest after being given a heart regulating drug instead of a blood pressure drug.

He died two hours after the Liguocaine was infused into his body. It was administered by a staff nurse in charge of three patients in the hospital's medical assessment unit.

The former delivery driver went to the accident and emergency department on New Year's Eve after suffering severe vomiting and diarrhoea.

He had been waiting for test results following an urgent referral to a gastroenterologist in Bolton on December 14 -- but test results had not been typed up until after Mr Richardson's death.

Mr Richardson, who had lost two stone in three weeks, was suffering abdominal pain and was admitted to the medical admissions unit just after midnight under suspicion of suffering a diabetes related disease.

Newly-qualified Dr Christian Macutkiewicz, described as "young and inexperienced" by the coroner, was on duty and decided to put Mr Richardson on Gelofusine due to blood pressure problems.

He was cleared of any blame over Mr Richardson's death. He told the court that he noticed that Mr Richardson had a thin, sallow look to his face and did not "look well".

He wrote instructions for the duty staff nurse to put up an intravenous drip and also verbally told her to use Gelofusine -- a drug which controls blood pressure.

Instead, the inquest heard, the nurse put up the wrong bag of fluid which poisoned Mr Richardson over two hours.

Consultant physician Dr Jacqueline Bene was among the crash team who attempted to resuscitate Mr Richardson, who was discovered collapsed as she carried out her daily morning inspection.

A ward sister alerted the crash team to the fact that the wrong drip had been given.

The nurse who made the mistake was reported as saying: "Oh s***! Oh s***! I've put up the wrong bag." Dr Bene urged staff to call the poisons unit at Guys Hospital, London, for advice on how to save Mr Richardson.

Guy's staff instructed resuscitation -- for more than one-and-a-half hours -- but this failed to save him.

A pacemaker machine was connected -- but it didn't work when it was switched on.

The hospital told the inquest that the pacemaker was not needed because Mr Richardson's vital signs had not returned. But the inquest heard that there was no back up pacemaker if it had been needed.

The inquest heard that on the morning of the incident the nurse reported feeling unwell and had been forced to wear glasses due to an abrasion on her eye.

Although she told her managers that her eyesight in her glasses was not normal, she reported that she could still read.

Director of Nursing Sue Reed, who headed up the hospital's internal inquiry, said that the nurse had also admitted to feeling unwell and had gone to bed early on New Years Eve with a view of not going into work the next day.

The nurse, described as full of genuine and deep remorse, has been unable to explain how she made the mistake but told hospital managers that feeling unwell was a contributory factor. The inquest was shown exhibits of both of the drugs after hearing that there could have been a mix-up because of new packaging of the Gelofusine.

But the different names of the drugs were clearly marked on each fluid packet .A pathologist from Salford's Hope Hospital, Dr Susan Andrew, carried out the post mortem examination and revealed that Mr Richardson had no underlying disease and that he died from Lignocaine toxicity.

A second cause was also attributed to diabetic ketoacidosis -- a diabetic condition causing metabolic problems.

The posioning would have affected his brain and his heart, the pathologist added. THE NURSE THE nurse involved in the tragedy has returned to work after being suspended.

Tracy Davies, medical risk manager at the RBH, said that the nurse is now working shorter days, to prevent her becoming tired, and is being supervised and given extra support by the hospital.

Her eyesight difficulties are also being closely monitored, ther inquest was told.

Mrs Davies said: "It was a tragic mistake, a human error. It was one of those unpredictable events -- a terrible mistake."

The hospital denied the staff nurse had been effected by alcohol -- insisting that she had gone to bed early on New Year's Eve.

Mr Cotter said: "It has been known in the medical profession to deliberately take life. Did the nurse co-operate with the inquiry?"

Mrs Davies replied that she had been very open and honest and has co-operated fully throughout. There was no question of criminal intent she said.

New policies to prevent this happening again THE hospital has introduced new policies to make sure this never happens in Bolton again.

Two nurses now have to inspect intravenous drips instead of one and all staff have been warned to be aware of drug manufacturer changes.

Mrs Reed, Director of Nursing, said: "The hospital is making continuous progress of learning and improvement."

The hospital is also looking into why Mr Richardson's original test results were delayed and their resuscitation policy is also being reviewed in terms of the faulty pacemaker.

All staff have also been warned to double check their procedures and have asked the drugs company to mark high risk drugs in bigger letters.

The hospital says that it is now working with all professional health people across Bolton to make sure that they are always aware of changes in the make and manufacture of drugs.

In a statement after the inquest,the Bolton Hospital's NHS Trust said:"This was a single, isolated incident. We have looked into every aspect of this incident because we, along with Craig's family, want to ensure that we have effective practises to minimise in so far as it is ever possible, the opportunity for human error.

"We have learned a number of lessons from this sad incident and are committed to acting on these."

Chief Executive of the trust, Mr John Brunt, will be speaking with the family, alongside the nurse who made the mistake, in a behind-closed-doors meeting at the hospital.

The family will then be given the chance to cross examine the nurse which was denied at the inquest.

THE family has expressed concern and anger that the nurse involved in Craig Richardson's death should continue working as a nurse.

Mr Richardson's sister, Karen Richardson, a qualified nurse and manager in an NHS Trust outside Bolton, said: "We feel this demonstrates a disregard for the loss of Craig's life."

The devastated family is now calling for the hospital to "work in Craig's memory" to make sure that this never happens again.

Miss Richardson said: "Craig was only unwell for two months prior to seeking medical advice from his GP, following which he ws referred to the Royal Bolton Hospital.

"The care he received can only be described as a catalogue of errors."

The grief-stricken family acknowledges that mistakes do happen but added: "the errors in healthcare are far too costly."

They continue: "Whilst Craig's death was the result of one individual's error, we also feel strongly that the NHS as a whole should learn some salutary lessons.

"During the past months, we have been in regular contact with the Royal Bolton Hospital Trust. They have been open and honest with information regarding Craig's care and we are grateful for this.

"Sadly, his whole episode of care demonstrated a complete systems failure, sometimes to an astonishing degree.

"We will keep in contact with the Trust to ensure that appropriate and robust actions have been taken, to ensure such a tragedy can never happen again."