Speaker 1: ♪ In January 2017 I was admitted to hospital with chest pain. It was ultimately diagnosed as pneumonia and everything went well to begin with except that I didn't notice I was admitted without a wristband to identify me. I didn't notice and nor did the staff and despite going through two wards and a series of interventions with drugs and intravenous drugs and moving ward, nobody noticed that I didn't have an identification wristband. I ultimately swapped identity with a patient in the next bed and was given incorrect medication. This made me very ill. The first drug made me violently sick and pass out. I said to the nurse, where are my Parkinson's drugs which I mustn't stop taking? And she said, but you haven't got Parkinson's. And I thought, oh wow, they think I look good. But in fact they thought I was somebody else. And when she realised that I did have Parkinson's and I said, and look, I haven't got a wristband either. She went, rather white, and she went and got me a wristband and my Parkinson's drugs were written up for me but it took about 10 hours before I was allowed to take them. They reacted with another of the drugs to give me wild hallucinations. And every time I shut my eyes there was a great big hole opened up on the ceiling full of snakes and lizards, all different colours, moving around. And I felt so ill. And I think ultimately it was decided this was caused by my Parkinson's drugs interacting with some of the incorrect drugs that I'd been given. On leaving hospital I needed to know what these drugs were that I'd taken and I'd got no information from the staff while I was there. So I made an approach through PALS, the Patient Liaison Service, to try and informally get the information because I didn't want to complain. I'm used to getting excellent treatment from the NHS staff. They're hard working and hard pressed and it seems ungrateful to complain. I have family members who work for the NHS. There's a whole host of reasons why I didn't want to complain. But I had an informal meeting with a consultant and a matron who'd been investigating my case and they wrote to my doctor implying that I was a rather confused old lady that had a temperature and therefore just imagined the whole thing. Actually I was only recently retired from being a company director. I was a qualified chartered chemist. I'd been travelling the world as a consultant up until just ten months before this. And I may have looked like a rather dejected granny when I was feeling very ill but in fact I had the tools at my disposal to investigate chemical errors. I was a chemist. I made tablets. So I just couldn't leave it at that. I was hopping mad. I had to make a complaint at that point. In the end we had two complaint meetings. The first one I was sent the transcript and it all looked very good but there were still some questions in my mind. I didn't have the full story at that point. And we had a second meeting which filled in some of the blanks that had been a good investigation from the pharmacy which indicated what potentially I had taken. But I have still not seen any final report about the incident. The one thing it did say is that one nurse had been blamed and was being given retraining. It was a system error. At least ten people missed the opportunity to see that I didn't have a wristband. And I was given drugs while I was unconscious and people signed for it. How did they know who I was? People will not come forward if they're going to be blamed for reporting errors and that just discourages people from being open and honest about complaints. I think there are three key things for the NHS to learn from this experience. First of all, for the nursing staff, listen to the patient. This would not have happened if I'd been listened to. Secondly, the managers need to make sure that staff are trained and know that they can report an error without being blamed. If they know that that is allowed and that is encouraged, then they will be honest and open. And finally, for the policy makers, make sure that this kind of problem has to be reported because if we don't report it, the problem is invisible and you have to first admit to a problem before you can solve it.