Hospice Patients Alliance: Consumer Advocacy

Two Daughters Report Mother Killed Due To Negligence
Of Hospice Nurses (Morphine Overdosage - Improperly Set Pump)

[beginning of report about negligent overdosage of mother due to morphine pump
incorrectly set by 2 hospice nurses; note that the daughters were also nurses and even then, were unable to prevent this death because they TRUSTED in the expertise of the hospice nurses!]


I would like to tell you about my families struggle with the local "Tertiary Care Hospital's"Hospice /Palliative care department.

My mother was diagnosed with Colonorectal Ca. She did well for about a year or so post chemo and radiation. The Cancer was then found in her liver.We had her move up to the city with us as 2 of us who live her are Nurses and felt we could take care of her and help her out more. Her home was aprox. 4 hours drive away.

Mom did well for quite a while. She was a very strong willed woman who did not like to take any medicine. When she started to have pain my family and I felt it would be to her benefit to involve the palliative care service at the hospital. We didn't realize what this could lead to. They helped us out with organizing appointments,getting prescriptions as needed, etc.

Mom was taking aprox. 1 to 2 mg of Morphine by mouth every 4 hours or so and certainly not every day. She had her good days as well as some bad.Her Abdomen started to get larger and that bothered her more than anything. We went on a shopping spree to get her some looser and more
comfortable clothes.

The Hospice Nurse would visit Mom and ask her if she was taking her medicine(mostly Morphine), Mom would politely say no. The Nurse used to get a little upset with her and tell her she needed it for comfort. We assured her that Mom would take it if she needed it.

As time progressed Mom and the Nurse developed a better relationship, didn't butt heads as much. One weekend Mom decided she was tired and a little depressed, she had herself admitted to the respite bed at the Hospital.(My sisters and I had been out for the evening and Mom was home alone with my brother) We were very surprised at this as Mom was doing fine. Palliative care felt she was depressed and even labelled her as suicidal. We got her best friend to come up to see her for a visit and she was out of Hospital that day, as happy as could be. Our Mom was funny like that, every now and then she needed a little extra attention. She raised 6 of us on her own after leaving my very abusive father,with very little money and we felt she deserved any attention she wanted!

Mom decided she would go back home for a visit after that. We helped her out and off she went to spend time with my other brothers and revisit her friends. Mom stayed home for about 2 weeks at that time. My sister and I drove down to bring her back when she called and told us she was ready to come back,she said this is where my home is now.That was aprox 2-3 weeks before everything came crashing down.

As time went on Mom 's belly grew to be uncomfortable and we felt she was embarrassed by it. She kept a low profile. We asked if any thing could be done to drain the fluid and they did try but it was loculated and they could not get at it, even by ultrasound.

We continued on and my sisters and I helped her with her baths(getting in and out of the tub).She had good and bad days still. On one "bad day' she was very weepy and I asked her if I might give her some "relaxing" medicine (Versed). Through a small needle. The hospice nurse had left us with all of these supplies as I have said my sister and I are both RN's and were caring for Mom.Mom was a little hesitant at first but I explained to her that it was the same medicine they gave her for her cataract surgery, she was relaxed with that.I gave her 2 mg and sat with her to make sure she was ok. she slept very well after that.

The next day the Hospice nurse visited and thought it would be good for all if Mom started on an Infusion of Morphine, Gravol and Versed. She told us all that Mom would be relaxed and it would lessen the worry we might have about her being uncomfortable. We said no as we did not think Mom would agree with it. The nurse asked Mom and she thought it might be ok. I think the good rest she had gotten with the small dose of Versed may have made her not concerned. As I have mentioned, Mom was fairly mobile and still pretty independent up until then. That Nurse started the "pump" at 1030( to run over 24 hours ) she left the house shortly afterwards only to run back into the house at 2:30 or so to reset the rate as she said it was too slow.She said she had mistakenly set it at 10 when she meant to set it at 20. The pump was set in MM per hour and I had not ever seen one like this so was not familiar, nor was my sister.

That night my Mom started to snore deeply. I thought she had a stroke or something awful as she seemed to be in a coma. Even though I am a Critical care Nurse and I did not even consider that it might be the drugs. My sister and I stayed in her bed with her that night. We called our brothers in Cape Breton to tell them of her condition.

At aprox 0430 she stopped snoring and at 0630 she woke up when we went to make her more comfortable. She was very bright and chatting with us. She said she was a little sore so I then looked at the syringe pump and it was empty!!!

I called the floor and told them what had happened. that the pump somehow went too fast. and they said they would have someone come as soon as was possible. They told me to give Mom some Morphine, which I did for pain.(2 mg).Mom said it would be ok. She said she was a little tired but when she woke up she would like some "Tim Horton's Soup". We kissed her and sent her off to sleep.

The next nurse came around 10 am or so. We showed the pump to her and she said "oh, that's wrong" ... she then drew up 20 mg of Morphine, 50 mg of Gravol and I think 25 mg of Versed as well as some scopolamine for any secretions Mom might have. Mixed them all together in a syringe and set it into the driver. She set the rate at 50mm and asked my sister and I to make sure the rate was 50 as she forgot her glasses. My sister and I both did this as was requested. She also gave us a prescription for another 200 mg of morphine, to have at the house if we needed it! The Nurse then gave us a new battery for the pump in case this one failed. My sister asked her if there was anything wrong with the pump and she said it appeared to be working normally.

She left shortly after that. We were all in the room about 30 minutes later and Mom was snoring again. We heard a long beep after about 45 minutes total. I said"what was that?" I took the syringe pump out of the bag it was in to find to our horror that it was empty!

We called the hospital immediately and they said they would get a hold of this"Nurse".She called about 10 minutes later and told us that that could not have happened, she told us to check the bed to see if it had come apart. She also told my sister that our Mom would not be there if she had gotten that much medicine so quickly. My sister told her that she basically wasn't as she was so sonorous. We told her about the large bubble on our Mom's arm from the infusion and that Mom was not responding to us anymore.

She told us she would come as quick as she could. My 2 Sisters and my brother sat and watched our beautiful strong Mother drift deeper and deeper into a coma. During which time my Mom vomited and probably aspirated her secretions. We called the covering family doctor for help as well. He told us to turn her on her side and clean out her mouth. We had done this already. The Palliative care nurse did not arrive until aprox. 2 1/2 hours later. She said she had been with another patient who was actively dying and then was stuck in traffic. When the Nurse came I asked her to show me on the pump where it said it was to run over 24 hours as the writing on the pump said MM per Hour. She said it was calibrated to run over 24 hours and I said even though it says per hour?

She put it in her bag and then after spending a little time with us, telling us we should talk around Mom as she could probably still hear us. She also suggested we call 911 to have an ambulance come and suction out my Mom's secretions. I told her that would not be appropriate and I was able to borrow a suction machine from my friends in emergency. She checked her pulse and respiratory rate. She said she had called the covering physician and he had advised her that if Mom's breathing was less than 6 to go to the hospital to get Narcan. I asked her what good that would do as it had been over 3 hours already. She offered to leave us more Morphine which we refused. We did not get the 200 mg prescription filled either! She said we could give her more subcutaneously and it might "settle her breathing". I told her we thought she had enough drugs in her now. I asked her why they gave the drugs subcutaneously and she told me that was their policy. She said that they were not allowed to give them IV but if I wanted to start an IV and give them to Mom that it would be all right and she "wouldn't say anything"!!!! She left shortly afterwards.

My Mom's breathing got noisier and noisier, to the point that she sounded like she was drowning. We continued to clear out her secretions but they just kept coming more and more.(She could be heard over the entire house.) She would initially gag on the suction catheter but after a little while she stopped doing that too. She continued to go deeper and deeper into a coma and her colour grew darker and darker, her hands grew cold(Mom always had warm hands). She left us at 7:15 pm that evening. We tried to say our goodbyes to her. We prayed at her bedside that she would go swiftly to heaven. We sat her up after she stopped breathing... for my brother who is confined to a wheelchair so he might kiss her goodbye as well. That tears at my heart still. He was so helpless sitting there watching all of this unfold. We did not even think to do this sooner for him... it was only when he asked.

We have met with the Palliative care nurses, the head nurse as well as the Medical Director and a patient care rep. Both Nurses admitted to setting the pump wrong. They said they thought it was "another" pump. We were advised to go to the Licensing body to have some action taken against these nurses. We did and they were given a reprimand only. Told to re-learn the 5 "rights" of giving medications! The RNANS also said they believed that there was credible evidence to believe that these 2 nurses made an "error" but they did not feel it would or should stop them from practicing Nursing.

During our meeting with Hospice the Physician told us that they have a lot of equipment they are responsible for. I told him that I was a Critical Care nurse and was responsible for many pieces of equipment and that it was my responsibility to know how it worked. He also told me that if someone was going to die from an overdose they would do so in the first hour. We told him yes, if it was given IV not Subcu, like my Mom. He told us that Mom was on a slippery slope and we said yes, but you did not have to push her off.

We have since sought legal council and are going for discovery in the near future. Initially the lawyers we spoke with felt it was not "worth our while" to pursue this as Mom did have a terminal illness. We assured them that this was not about money. We are far from wealthy but some good must come out of this tragedy.

The hospital seems to feel that the drug infusion did not cause our Mom's death. The head Nurse told me I should speak to someone about the drug infusion as she too believed it did not cause Mom's death.We disagree.

We want them to take accountability for their actions and this may be the only way how. We get the feeling that it really isn't such a big deal as she was "on a slippery slope" to quote that physician. We have also met with the Risk Management people at the hospital and they refuse to release their findings to us. I hope to heaven that this will help someone else ... I can only think that these nurses are out there setting infusions wrong and injuring or killing other! I and my sister are both RN's as I have said and we did not even think to check that stupid machine ... I am sure others would not either.

I have been witness to many deaths as I am an ICU/Emergency Nurse. As well my sister has worked in many areas including extended care facilities and has seen many deaths too. This was truly horrible. We wanted to maintain our Mom's dignity and they stole that from us as well as her last precious bit of time however long it may have been. She did not get to spend time with her new Grand Daughter, nor say goodbye to her family in a way she deserved.

We will never forget that day nor at this point can we forgive. Our only wish is that they be held accountable for their mistakes. Thank you for trying to make others aware of this.

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