Jessica Hilary Bovill died after she was taken to Canberra Hospital in 2020. Photo: James Coleman.
CONTENT WARNING: This article contains information some may find distressing.
The ACT Government says it has made “a suite of changes to improve patient safety” after a woman died due to the mistakes made at Canberra Hospital during her treatment.
Jessica Hilary Bovill was found unconscious after consuming a medication in overdose quantities, ACT Coroner Ken Archer said during an inquest into her death.
During her treatment at the hospital, she was “administered sodium bicarbonate in doses that were far in excess of therapeutic requirements” and suffered injuries consistent with brain death, he said.
The 43-year-old mother of three died in December 2020 and the coroner found an error in sodium bicarbonate dosage caused her death.
“The ACT Government acknowledges the impact Ms Bovill’s death continues to have on her family and loved ones and again extends its apologies and condolences for this tragic loss,” Minister for Health Rachel Stephen-Smith said when presenting the government’s response to the inquest earlier this week.
She said while every effort was taken to deliver safe care, Canberra Health Services (CHS) “acknowledges that clinical incidents do occur, even with the best controls in place”.
“Since Ms Bovill’s death and prior to the handing down of Coroner Archer’s recommendations, Canberra Health Services implemented a suite of changes to improve patient safety,” she said.
“The hardwiring of certain functions in the DHR [Digital Health Record] now ensures staff have access to patient information and evidence-based prescribing.”
Coroner Archer made two recommendations in the inquest, including sodium bicarbonate only be available at a central point in the hospital.
He also recommended Emergency Department staff know to seek out more advice from a toxicology consultant or consult guidelines when patients arrived suffering from a potential overdose involving the medications in Ms Bovill’s case.
Rachel Stephen-Smith says the government accepts the recommendations from the inquest into Ms Bovill’s death. Photo: Michelle Kroll.
Ms Stephen-Smith said the government had accepted and implemented both recommendations.
She said after Ms Bovill’s death, CHS developed and issued a new guide to provide staff with clear escalation points to support decision making related to life-threatening poisoning presentations.
“The guideline requires that staff contact the Poisons Information Centre in the event of any patient requiring antidote therapy and if otherwise clinically indicated,” she said.
This centre is a 24/7 service staffed by clinical toxicologists.
Ms Stephen-Smith said a review found it was critical for sodium bicarbonate to be available in areas such as emergency departments and intensive care units to ensure it could be administered immediately.
“Canberra Health Services will continue to have small amounts of sodium bicarbonate in emergency departments in secured resuscitation trolleys as an available first line treatment for poisoning,” she said.
“However, the volume of available sodium bicarbonate has been reduced since Ms Bovill’s death.”
Ms Stephen-Smith said when the DHR was implemented, restrictions were placed on the ability to order sodium bicarbonate.
“Within the DHR, sodium bicarbonate requires a documented order before it can be administered – a verbal order cannot be given,” she said.
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