It was his first afternoon as a salaried GP. A call came in from a local nursing home requesting analgesia for two elderly residents. Dr Nayak-Kokkarne, a practitioner with a number of years’ locum work behind him, prescribed oral morphine.
He was absolutely devastated when he heard that both patients had died. The moment set in train three years of criminal investigations and then a trial for manslaughter that caused him great emotional distress. He was ultimately acquitted but the experience profoundly changed his view on the way he practises medicine.
“I was absolutely incredulous when a colleague called to find out what lay behind the two patients’ deaths,” he recalls. “It was a terrible shock. I have always been so careful in all areas of practice, particularly in prescribing.”
“He was interviewed under caution and eventually charged with gross negligence manslaughter three years later, an offence that carries a maximum sentence of life imprisonment.”
It transpired that Dr Nayak-Kokkarne had inadvertently prescribed 20mg in 1ml of oral morphine using the practice computerised drop-down list. He had intended to prescribe 10mg in 5ml, but the stronger preparation appeared first on the list.
He was interviewed under caution and eventually charged with gross negligence manslaughter three years later, an offence that carries a maximum sentence of life imprisonment. Acting in his defence were Ian Barker from the MDU in-house legal team, and a team of barristers. The defence argument was constructed around three key factors in the case: the computerised prescribing system, the shared responsibility for ensuring a system is safe and whether the drugs caused the patients’ deaths.
“Ian was tenacious, always looking for another angle, and in the end his persistence paid off. He really helped me emotionally, too, whenever the case threatened to overwhelm me. I have huge respect for him and, in fact, now when I am in a difficult situation, I think ‘what would Ian Barker do?’.”
For Dr Nayak-Kokkarne, his acquittal marked the end of a distressing four years, with a lengthy court case and the threat of a GMC fitness to practise hearing hanging over him. Once the court cleared him, the GMC also evaluated the matter, but concluded its investigation with no action following lengthy representations on his behalf. They removed the restrictions on his practice they had imposed at the start of the case.
Today, he is a more cautious practitioner. If a prescription comes across his desk for signing, he never assumes that all the checks and balances have been done. “Never fall into the trap of everyone thinking someone else has done it,” he advises.
He has learnt to be acutely aware of the possibility of error, and the need not to let errors go unchallenged, not just by him but by everyone involved in healthcare systems. “Medicine is an inherently risky environment where there is no truly safe system unless everyone is vigilant. It takes a team of people to make a system safe, and everyone has their part in managing risk and ensuring patient safety.”
Our thanks to Dr Nayak-Kokkarne for allowing us to publish some of the details of his harrowing case.