Furious at the mistake that could hav... - British Heart Fou...

British Heart Foundation

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Furious at the mistake that could have killed me .

Notdead profile image

Hi everyone,

So as I wrote a few weeks ago the cardiologist is was for giving me pills for af , I finally got the call from cardiology saying this was going ahead and when I got my next prescription to make sure and tell them to add this in ,, so on Monday , called up the doctors told them on their answering machine all the medication that I require , also added at the end , “ there should be a note from cardiology with a new pill for me for af so if you could add that please’ . Easy enough right ?? So fast forward to Tuesday and I get my prescription, take the new pills three times a day , ok no problem. Yeah big problem I’ve been taking these pills since Tuesday I have felt like my heart is about to explode since Wednesday morning, last night I never slept because I felt that if I slept I was going to have another heart attack. The medication they so carelessly gave me is an anti sickness medication that I got over a year ago ONCE ! This medication can cause so many issues. I am furious! Absolutely furious!! What do I do other than not take any ??

43 Replies

Don’t quite understand the post: are you saying they gave you domperidone instead of a cardiac med for the AF? Or domperidone labelled incorrectly as the cardiac med? The first would be a mistake by the GP, in which case you need to speak to them and potentially make a complaint. The second would be a mistake by the pharmacy, in which case you need to speak to them and make a complaint. I will also say that I’m very familiar with domperidone, though, and was very recently talking to a consultant at the Brompton about it: although there is a theoretical risk of arrhythmia whilst taking it as mentioned in the image you attached, it’s usually only associated with specific, pre-existing cardiac conditions. In practice, if you don’t already have elongation of the QT waves or a ventricular arrhythmia, the consultant I was talking to said she’d never seen a single case otherwise in 25 years as a doctor. My understanding is that AF isn’t likely to increase the cardiac risk because it’s an atrial condition rather than a ventricular one, and it’s not a conduction disorder. That’s not to say that what’s happened is ok or right, or that it didn’t make you feel poorly, simply trying to reassure you slightly. Stop taking it as you already have, and speak to the GP tomorrow. We’re no longer allowed to request meds over the phone in my neck of the woods, it has to be in writing, in part to prevent things like this from happening, and so that there is a record in the event of anything going wrong.

Notdead profile image
Notdead in reply to Charlie_G

Hi Charlie yes , I was given that medication instead of the af medication.

Notdead profile image
Notdead in reply to Charlie_G

I should add , I had a stemi three months ago , two stents .

What Med should of been prescribed?

Notdead profile image
Notdead in reply to Gaz_chops

I don’t know , all I do know is it’s supposed to be a water pill ,I don’t know the name of it

Cat04 profile image
Cat04 in reply to Notdead

Indapamide, does that sound similar enough for the mistake to happen?

Notdead profile image
Notdead in reply to Cat04

It was supposed to be spironolacpone 25mg .

Cat04 profile image
Cat04 in reply to Notdead

Not very similar to domperidone!

I know when I ask the receptionist for a prescription, I have to know name and strength before they ask gp. In these busy times, even gp can forget to re-read cardiologist report on new medications. We recently had to go to gp to clear up a mistake on medication list, bit tense time. She had to go back to a few reports before she acknowledged mistake. The pharmacist should maybe have picked it up, as ours did, I only use one, so they know what medications are normal for us. Take care.

Notdead profile image
Notdead in reply to MONIREN

I’m just so angry, I have felt off for days and last night I really thought ok maybe I should get to hospital now , I felt that bad . I can think of no reason at all why they would send me medication that I haven’t had for over a year and that I’d only had once . It isn’t even on the radar . The only reason I have figured this out is because I was looking for rennies for heartburn and seen the old medication in the drawer , even at that I thought ok maybe that’s what I’m supposed to be on , but tonight I’m still feeling bad so I decided to look it up on google . So I can see no reason at all for this mistake . My daughter n law is a nurse so I called her and she’s of the same wavelength, told me don’t take anymore call the doctor in the morning and raise hell . She’s furious as well . I think though that I’m going to call cardiologist nurse in the morning first and take it from there . I don’t want to call the doctors gp surgery and end up getting upset .

Lucymoo profile image
Lucymoo in reply to Notdead

I understand that you are upset but maybe ask what happened and why the mistake happened so you can understand more before getting angry. You phoned leaving a message within knowing what the medication was and maybe the cardiology letter hadn’t arrived in time and the surgery tried to be helpful and prescribed what they thought you meant a simple case of crossed wires. You have quickly identified the problem and should get onto the correct medication. Being angry doesn’t do you any good it’s damaging to your health. Better to find out what went wrong to avoid mistakes in the future. Take care

Notdead profile image
Notdead in reply to Lucymoo

I know , I’m not angry so much this morning either I haven’t called yet but I’m just about too , in what you are saying , that is true maybe the letter hadn’t reached them and they were trying to be helpful,, but they could have called me , they have done that before , they can see clearly in my notes the medication I take regularly it’s right in front of them when they click my name . Again they should have called me and clarify.

Lucymoo profile image
Lucymoo in reply to Notdead

My own surgery processes 700 prescriptions per day so sometimes they have pressures too it’s not easy for everyone

Notdead profile image
Notdead in reply to Lucymoo

Just spoke to the cardiologist nurse in charge of my care , he isn’t a happy bunny over this mistake either but I’ve caught it , so he is emailing them this morning and I should have the correct medication by the end of the day .

Lucymoo profile image
Lucymoo in reply to Notdead

Well sorted

Milkfairy profile image
MilkfairyHeart Star

No medication is without some risk.A risk has to be quantified. A risk is not a certainty.

I was once prescribed beta blockers which is contraindicated for me as I live with vasospastic angina. I ended up in hospital with unstable angina.

My Cardiologist apologised he got it wrong. Humans make mistakes.

The issue of prolonged QT interval was found in women over 60 years old given IV domperidone. It was in the past available over the counter without a prescription.

It has some interesting useful side effects such as increasing the milk supply of breastfeeding women.

I suggest you ask who is responsible for writing the prescription.

Next thing to consider is who dispensed the prescription that is the pharmacist's responsibility.

Notdead profile image
Notdead in reply to Milkfairy

I know what you are saying , I was once given beta blockers and ended up having an asthma attack that lasted a week cus of it , the chemist in boots went mad . Humans make mistakes I know , but end of the day why give me a medication from over a year ago that I shouldn’t be on , and give it to me at the same time as all the heart medication? Surely that should have rang some bells ? Thing is we trust that what they are giving us will help us , we don’t expect it to make us worse . I’mNot no angry now I’ve caught it before any damage was seriously done , plus apart from giving me the wrong stuff I still haven’t gotten the meds I should be on .

Handel profile image
Handel in reply to Notdead

Get a letter off telling them to remove the offending item from your repeat prescription, particularly as there must be something on your records pointing to severe reactions! I had the same thing happen to me a few years back. My son, who is allergic to penicillin was given this for a severe ear infection. It's clearly on his records that he'll suffer anaphylaxis but hey ho!! He had the foresight not to take it!!

Good luck - mistakes do happen but I agree with you that they shouldn't.

Best wishes. Jan xxx

I have only been on medication since June following my heart problems, last week i went for my first lot of tablets that had not been issued by the hospital.

As I am careful I checked beforehand that the tablets I was given matched the ones I had, I noticed one was missing, went back to the chemists and they apologised and gave me the correct order. No damage done.

What I have also noticed is that the hospital on my tablets stated one to be taken in the morning, whilst the latest lot states one to be taken once a day. I will continue to take in the morning and we transfer to the old boxes when they are empty.

Sorry for the length but the moral of the story is that when you receive them check you have the right ones, and if anything is different or you need a explanation then do speak to your surgery/chemist.

Hi notdead. I sympathise with you. Not only are you still getting your head around the whole Heart issue ( which is enormous and sooo scary)You now feel betrayed by those in charge of your care. But as others have pointed out mistakes do happen. They certainly shouldn’t and there are several checks that were obviously not taken.

I doubt you will get any satisfaction from your complaints other than getting them to be a bit more vigilant with your meds.

What is important is that you do not get yourself anxious over this. You are here and you’ve faced a very large hurdle which has definitely not dimmed your marbles .

In hospital, I like yourself, had several Med related admissions . I was 10 days into heart scenario. Drug nurse came by to hand me some pills. One was a statin ( I was taking 5mg - she was giving me 10mg which I refused) she had a heavy accent which made her difficult to understand but the. Second pill she was pushing was for (?!,.’jk) sorry I dint understand. It’s for your gout. ….I Do Not Have Gout. Oh yes you do you must take this tablet.

Of course I refused point blank. The next day I told the cardiologist. He looked at the nurse who was with him and she stammered “ yes there was a mix up”. Cardiologist just said “ well no one ever died if a gout pill”

Really- we’ll I dint want one thank you.

You have to be very careful now our care seems to be very much down to us now. Difficult to see a doctor and Cardiologists have put stents in and given you meds so I’m their book your ok to be signed off.

Read as much as you can . This site will be a godsend.

Wishing you very good health and good eyesight to spot the mistakes

Obviously there were several errors here, but I wonder why you weren't more specific. When you got the call from cardiology, did you not ask for the name and dosage of the new medication? Imo, that's something we all should do. I always ask what it is and why they want me to take it. If you had told your surgery the name of the new drug, it may have helped to avoid this error.

Notdead profile image
Notdead in reply to Ecki

Hi ecki, yeah I shoulda have done that but yano what I didn’t I didn’t even think to do that , I expected them to know this information and pass it on to the go surgery and for me to just trust they gave me the right stuff . How stupid eh

lateguitarist profile image
lateguitarist in reply to Ecki

Very good point and attitude. I think this came up in another post, some people have a bit of a tendency to just accept and/or not question, and to even remain ignorant of the actual problem. I am not saying this is the case here at all, but in general I feel it is even a responsibility on the patient to get themselves clued up regarding their problems. I have a mate who is like this, he would walk down the road with his underpants over his head if the GP told him to.

‘Update ‘ Called the cardiologist nurse in charge of my care . The medication I should have been put on is spironolacpone 25mg . I definitely should never have been giving the domperidone and especially prescribed to me at the same time as heart medication he is emailing them now and I should have the correct medication by the end of the day . I’m sorry if a few replies seem ratty but I actually thought I was on my way out on Saturday and I would have continued to take these pills thinking I was supposed too . I guess lesson learned , check the dam medication myself and don’t expect the doctors too . I will be far more careful in future .

I agree - we need to be our own advocates and be super vigilant and learn all we can about our own conditions & medications, once they’re settled. It concerns me though that many are too ill or frail or shocked to be able to do that.

I was given domperidone a few years ago in a hospital but discharged without it. I was very poorly & asked my GP to prescribe whatever anti-sickness I was having in hospital. A few days later, when I felt I was about to die, I mustered the energy to read the leaflet. When I got through to the GP to point out that it was unsuitable for heart patients he said ‘good spot’ 😳

Notdead profile image
Notdead in reply to Ads568

Thank you for understanding, this medication is brutal I still have it in my system and I still feel like I’m having a wee mini heart attack , I’m not sure people who haven’t been on it understand how serious it is and how bad it can be for you . My cardiologist nurse does and he’s livid.

Ads568 profile image
Ads568 in reply to Notdead

Yes, I now ALWAYS include domperidone in my response when asked if I have any allergies. When I do, various medics reply 'oh we don't use that anymore anyway', but I will continue to include it, just in case!

Best wishes for your speedy recovery from the episode.

Sorry Notdead but this is not the way these things work. If your cardiologist wants to change your medication or add something additional then he/she should write to your GP requesting this and the GP practice should amend your prescription accordingly. It should NOT be up to you to tell the GP what your new medication is.

I suggest that you take this up with the GP practice as they are the ones who issued the prescription. If they prescribed domperidone in error instead of spironolactone then they are at fault but if they were asked by your cardiologist to prescribe domperidone then you need to take the matter up with your cardiologist. Perhaps you should also discuss your medication with them. Spironolactone is not specifically for treatment of AF, it is a form of diuretic.

Notdead profile image
Notdead in reply to Exie8

Yeah I have spoken to the go surgery now and turns out the people at fault is the actual chemist not the gp, the surgery sent the prescription for spironolacpone to the chemist last Tuesday, the chemist is now claiming they didn’t receive this until today which is total bollocks because on the same script was my painkillers, my doctors phoned me this afternoon and apologised for what has happened and he is going to investigate this further he is not happy either

Notdead profile image
Notdead in reply to Exie8

I should add here , there is no excuse /reason whatsoever for them giving me domperidone at all . This is one of the reasons it’s being investigated now . Also add , that ten mins after the doctor’s called the chemist to enquire wth happened my spironolacpone was brought to my door . Funny that eh . What can you do though , it’s done . And I’m ok

Spironolactone is a diuretic, a water tablet. I was on it afew years ago.

We do really have to take care of our own health and sadly, we can't always rely on Doctors or anyone in the Health service to get it right. We must check out medication; purpose, side effects, compatibility with other drugs etc.

I don't take any of the drugs prescribed by my cardiologist.

I think that is pushing things a bit far, people are only human and we do have a responsibility to help in any way we can. Why do you not take any of the prescribed meds? I have come off some of them, due to my own lifestyle changes, but not all?

I'm not sure what you mean by pushing things a bit far. It's because people are only human that we have to be careful and double-check our meds. Mistakes happen, as the OP has described. Are we getting the right meds, in the right quantities, are they compatible with each other, what are the side effects? etc etc.

Healthcare staff are really stretched, especially now. I like to take responsibility for my own health but that's just a personal decision. Other members of my family have taken a different view and will do whatever the doctors suggest.

I don't take any of the prescribed meds because I can see no reason to do so. I follow a holistic cardiologist and take his suggested vitamins and supplements.

I meant that your statement "we can't always rely on Doctors or anyone in the Health service to get it right" is in my opinion very over critical and in most cases not true. Yes they are only human and will make mistakes, but on the whole I for one am extremely appreciative of our NHS, there are many in other countries that can only dream of such a service."I don't take any of the prescribed meds because I can see no reason to do so" are you medically trained then? What makes you think you know better than the trained professionals that develop and administer theses drugs? They are keeping millions of people alive or preventing them from getting further symptoms. I presume you are one of the ones that also refuses to be vaccinated then? Good look with the holistic approach, may we know who this "holistic" cardiologist is?

May I ask…what vitamins & supplements does your holistic cardiologist suggest you take ?

Hi Boo Boo.

He recommends these four which he calls the "awesome foursome" for heart health; coenzyme Q10 (CoQ10), L-carnitine, D-ribose, and magnesium.

I also follow the Heart Tech protocol which is available here: I'm new here and am not sure what sort of links are allowed:


I also take Hawthorn, Berberine, Vitamin C, iodine, collagen, and other products.

Milkfairy profile image
MilkfairyHeart Star in reply to Lesquatrescentscoups

A registered Healthcare professional is required to provide evidence based information as part of the shared decision making process with their patients.

Can you holistically treat a heart attack?

Hi Milk Fairy,

When I was in hospital the cardiologist didn't provide any evidence based information or share the decision making process with me. I was able to get some information from the very helpful nurse on the helpline at Cardiomyopathy UK when I returned home.

I don't know anything about treatment for heart attacks. I should think a heart attack is a medical emergency rather than the sort of chronic conditions that holistic cardiologists treat with a focus on nutrition, lifestyle, and exercise.

Milkfairy profile image
MilkfairyHeart Star in reply to Lesquatrescentscoups


I am sorry the doctor you spoke to was unable to provide you with evidence based information. There is plenty of evidence.

There is another support group

Pumping Marvelous which provides very good information.


Is the protocol you are following based on research evidence?

The National Institute for Clinical Evidence NICE issue the following guidelines about how to care for people living with heart function issues.

This group of patients survival has greatly increased in recent years through treatment by medication and devices such as pacemakers.


I respect an individuals choice. I also hope that everyone has the opportunity to discuss their care with an experienced knowledgeable Cardiologist.

Hi Milkfairy,

Thank you for your comment. I'm going to follow up on the links you provided.

The cardiologists I follow provides links on his website to all the published research on which he bases his recommendations.

Thank you again.

Milkfairy profile image
MilkfairyHeart Star in reply to Lesquatrescentscoups

Would you feel able to share these references with the forum members?

Linus Pauling views are not without controversy and some of his theories about Vitamin C have been disproved by others in particular the Mayo clinic in the US.

He also believed in a form of eugenics which many would find totally unacceptable.

To date I do not believe that it has been shown through a large scale, randomised, blinded trial that coronary heart disease can be reversed.

Probably further progression slowed down or stopped.

Hi Notdead, I have had problems with prescription as well. I am allergic to a lot of medications. Because of this, I made a list of them with my side effects. I carry them withme. I compare them to prescriptions I receive as well. If I can't take, I let the pharmacist know. I also look up what the prescription is for. Yes, mistakes are made and it only takes one to kill you. Instead of being angry, I took control over my over safety over 10 years ago.

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