At least nine people died in the UK because the National Health Service (NHS) used syringe pumps that did not meet internationally approved safety standards in a bid to save cash, The Independent reports it has been claimed. Thousands of lives were put at risk as Britain’s health service continued to use equipment other countries had banned, an investigation report found.
Experts say the number of fatalities linked to the pumps may actually be many times higher – but no record was ever made because of “institutional indifference” to elderly patients in their final days.
The report says doctors had long been concerned that staff confusing two different models of the same pump – the Graseby MS26 and Graseby MS16A – could result in a day’s dose of drugs being delivered to a patient in a single hour. The NHS itself gave the instrument a rating of one star out of five in a 2008 procurement guide.
Yet despite these warnings and concerns, the report says the service’s National Patient Safety Agency (NPSA) waited until 2010 to issue a rapid response report, warning hospitals that a number of deaths – including four in the previous year – had been caused by the pump’s safety flaws. Even then, health bosses decided against an immediate recall and instead actioned a five-year phase out.
The report says the decision was made, at least in part, because of the financial implications of immediate replacement.
Explaining the decision to phase out the pumps, an official briefing note sent to NHS CEOs in 2010 says: “Longer periods of transition will reduce cost… However, prolonging the use of both types of devices increases the risk of confusion and therefore error.” The investigation has identified at least four more deaths linked to the pumps since then.
The report says in June, the then health secretary Jeremy Hunt said he would look into whether the pumps should have been taken out of service sooner. “We need to be absolutely certain that the NHS does react as quickly as possible when you have suggestions a piece of equipment is not safe,” he said. “Urgent guidance was sent out in 2010 and they were finally removed from use in 2015 but we will look at whether that was as quick as it should have been.”
The NHS said the pumps had been phased out rather than stopped suddenly to avoid patients going without pain relief. Aidan Fowler, national director for patient safety at NHS Improvement, said: “In issuing the patient safety alert across the NHS in 2010, England and Wales became the first two countries to set an achievable target for replacing all Graseby MS16/MS26 devices with the newer models.
“The alert urged all NHS organisations to phase out these devices as soon as possible but no later than by 2015.
"This deadline was set to avoid the risk of patients going without access to this important source of pain relief due to the expected time needed to source an acceptable alternative device and ensure healthcare staff were appropriately trained in how to administer it."
He said it was believed no older-style devices were in use anywhere within the NHS. "If there are instances, we encourage NHS trusts to notify us so that we can understand why," he added.
“It is right that as a system, we consider if we can learn from the past to make the NHS as safe as possible for patients.”
[link url="https://www.independent.co.uk/news/uk/home-news/nhs-syringe-pumps-deaths-graseby-ms26-ms16a-a8498151.html"]The Independent report[/link]