Deadly Handwriting

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Deadly writing

Does a legible hand make a difference?

On 18 October 1994, Carole Burwash was given 30mg of diamorphine, instead of 3mg, at Princess Grace Hospital in London. She suffered brain damage and died.

The Westminster Coroner said at an inquest on 2 July 1996 that the prescription, written by the consultant anaesthetist Dr Giok Lim, was unclear and dreadfully written. The resident medical officer, Dr Richard Hornabrook, who administered the drug, and the staff nurse, Mandy Hatcher, both read the drug chart as saying 30mg.

Press reports, The Times, 3 July 1996
“Woman dies after
doctor misread handwriting.”
“Hospital blamed in
report on woman’s death.”