Health minister's apology cold comfort for family of woman who died due to a medication error at Canberra Hospital

Australia Broadcast Center

15-05-2025

It's been more than four years since a mistake at Canberra Hospital resulted in the death of mother-of-three Jessica Bovill.
For her husband, Bill, life hasn't got any easier.
"We had everything. We were about to have more," Mr Bovill said in a statement to the ABC.
Mrs Bovill, 43, was taken to the hospital after overdosing on her prescribed anti-depressant medication in December 2020.
In his findings handed down in February from the coronial inquest into her death, Coroner Ken Archer found Mrs Bovill was given sodium bicarbonate during her treatment "in doses that were far in excess of therapeutic requirements".
Mr Archer found that the error in the dosage of sodium bicarbonate caused Mrs Bovill's death.
"The reasonable survival prospects she had were lost because of the administration of sodium bicarbonate in excessive quantities," he said.
The coroner made adverse comments about an emergency department specialist, anonymised as "Dr TX".
"Dr TX, whilst undoubtedly busy, made clinical decisions based on inadequate consultation and without reference to available and authoritative clinical guidance," Mr Archer said.
For Mr Bovill, the actions of Dr TX have haunted him.
"No one survives what Dr TX did. No one," he said.
Responding to the coroner's findings, Health Minister Rachel Stephen-Smith told the ACT Legislative Assembly on Thursday she was "deeply sorry", acknowledging the deficiencies in Mrs Bovill's care.
"I extend our sincere condolences to Jessica's family and apologise for the shortcomings in her care," Ms Stephen-Smith said.
"Systems and processes in place at the time of Jessica's presentation let her and her family down.
"I am deeply sorry and can ensure Jessica's family and the wider community that Canberra Health Services (CHS) is committed to ensuring that no other family experiences this pain."
Ms Stephen-Smith said a series of changes had been implemented following Mrs Bovill's death.
"CHS has learnt from Jessica's case and has hardwired changes to stop this happening again," she said.
Among the changes, Ms Stephen-Smith said new protocols have been put in place to give clear guidance for hospital staff to follow in similar life-threatening poisoning presentations, including the important of consulting the Poisons Information Centre.
She also said the accessibility of sodium bicarbonate was reviewed followed Mrs Bovill's death, and that its availability is now more restricted.
Ms Stephen-Smith said the introduction of a digital health record (DHR) system would also alert staff to possible prescribing errors.
"At the time of Jessica's admission, sodium bicarbonate could be administered by verbal order, with the order recorded on a paper based chart," she said.
"The DHR does not allow verbal ordering of sodium bicarbonate … and it ensures that situational awareness is maintained."
The apology from the minister is cold comfort to Mr Bovill, who has called for her to resign.
He also echoed a call from the family of Rozalia Spadafora, who died at Canberra Hospital the day after her fifth birthday in 2022, for a royal commission in the ACT's health system.
He said he spent more than three years thinking his wife had died because of self-harm.
"We were told that they had treated Jess with sodium bicarbonate, that they had given her more than they normally would, that there would be an investigation," he said.
"I didn't understand the implications of this. When your whole world has been torn apart, you don't think to ask too many questions.
"Later that week, my daughter, eldest son, and I, sat through a meeting with a social worker, and were told that Jess died by suicide.
Mr Bovill said he'd also like to see reform in the coronial system to make it more "restorative, rather than combative" as he said it had been for his family.
"I so wish she were still here," he said.
The apology from Ms Stephen-Smith on Thursday came just 24 hours after she delivered a separate apology, following another death at Canberra Hospital.
Sharyn Kaine, 73, was admitted to the hospital in 2021 after experiencing abdominal pain and was given a dose of paracetamol that was not adjusted for her body weight.
She died a few days later, which a coronial inquest last year found was a result of paracetamol-induced liver failure.
In this apology, Ms Stephen-Smith told the ACT Legislative Assembly safety mechanisms were now in place to ensure similar failures don't happen again.
"Sharyn's death and this inquest is a timely reminder that all medications may have serious side affects at the incorrect dosage," she said.
"I extend my sincere condolences to the family and apologise for the shortcomings in care that resulted in Sharyn's death.
"Canberra Health Services is a different organisation today than it was at the time of Sharyn's death."
Through the introduction of the DHR, Ms Stephen-Smith said if Ms Kaine was admitted now, her paracetamol order would go through a series of checks.