James Paget University Hospital makes changes after patient is mistakenly given medicine overdose

Shelbey Monk, with a series of letters exchanged with the James Paget University Hospital and a phot

Shelbey Monk, with a series of letters exchanged with the James Paget University Hospital and a photograph of her mother, Susan Jones. Picture: David Hannant - Credit: Archant

A hospital has introduced more stringent prescription guidelines and placed a nurse on restricted duties after a cancer patient was wrongly given 10 times a recommended dosage of ketamine.

Grandmother Susan Jones, 57, was being treated for stomach cancer at the James Paget University Hospital in Gorleston when a nurse mistakenly administered a 2ml dosage of the tranquilliser, instead of 0.2ml.

The mistake came after a miscalculation and confusion between two nurses when determining the correct dosage to administer.

As a result, Miss Jones, of Bradwell, suffered a series of hallucinations, including mistaking a fly for Batman and a nurse for the devil.

Shelbey Monk, one of her six children, who was with her at the time, said: 'I'm still haunted by what I saw in that room. After being given the drug she starting clinging to her bed and asking what was happening to her.

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'She started punching the air and shouting and told me it felt as though her face was slipping off.'

Mother-of-two Mrs Monk, 33 of Burgh Castle, added that the incident stuck with her mum for the remainder of her life.

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She added: 'She became frightened of taking medication in case the same thing happened again. During the overdose, she became terrified of the tassels on my scarf and when I wore it again she made me take it off.'

As a result of the mistake, the hospital took the nurse off of Miss Jones's care, as well as providing her with additional training.

The hospital trust has also put additional measures in place to prevent it happening again.

Anna Hills, director of governance at the hospital, said: 'As a trust, we are a learning organisation and committed to putting matters right when errors occur.

'Following this incident, a full action plan was drawn up and implemented. This included strengthening the dispensing procedure for ketamine on ward areas, limiting supplies to smaller quantities and putting in an additional approval by a pharmacist.

'The staff member involved was immediately placed on restricted duties and is undertaking additional training.'

Miss Jones died on June, 22 2016, more than two months after the incident on April 11, after losing her battle with cancer.


The incident was investigated by the hospital, which classified as a 'serious internal incident'.

Mrs Monk said she wanted it to be reclassified as a 'never event', the most severe incident type in the classification.

She said: 'My opinion is that this should thought of as a never event and if it was reclassified as such I would feel like I have gotten justice for my mum.

'The frustrating thing is though, if the nurse would apologised in person I wouldn't have even made a formal complaint.'

The hospital's director of governance Anna Hills added: 'The incident was investigated and classified appropriately, following guidelines and definitions.

'NHS England provides us with very strict guidelines of what constitutes a never event, which includes a list of cases that fit this description - this case does not feature on this list.'

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