A DOCTOR made a mistake. An old woman died. Whether one led to the other, even the coroner could not decide.

What did emerge at the coroner's inquest into the death of Madam Koh Ah Tow, 88, was a series of mistakes made at Clementi Polyclinic in March last year.

First, patient and doctor were apparently mismatched. The doctor could not speak Mandarin and the patient and her caregiver did not speak English.

Then, the doctor prescribed the wrong dose of heart medicine digoxin. Madam Koh was given four times the dose she should have received. This error was not picked up at the pharmacy, which should act as a safety net. Pharmacists are even more highly-trained than doctors to understand the effects of drugs on patients.

A 0.25mg dose for a frail old woman should have set alarm bells ringing, especially because it was four times higher than the 0.0625mg dose she was already taking. Another mistake was the higher dose of warfarin, the blood thinner she was given, and the follow-up scheduled for two months later, instead of the usual two weeks.

The reason for the late review was because the woman was old and not very mobile. But the doctor involved agreed at the inquest that when the dose for the blood thinner was raised, the patient should have been reviewed a week or two afterwards.

Madam Koh died of heart failure nine weeks after her visit to the polyclinic. The dead woman's son has decided not to pursue the matter. 'My mother is already dead. I don't want to harm the doctor. The doctor's quite young. She made a mistake. Let her think about it,' he said.

His magnanimous attitude deserves praise. It is sad that an error may have contributed to his mother's death. But little good is served in trying to apportion blame. Everyone knows how busy polyclinic doctors are. The doctor is human and given the large number of patients she has to see each day, errors happen.

What is important now is to learn from the error and put in checks in the system so such mistakes do not happen again.

The National Healthcare Group, which runs Clementi Polyclinic, has done just that. It has taken steps to prevent similar mistakes from happening again.

A spokesman for the group said: 'We have put in place systems to facilitate the openness to learn, encourage the adoption of best practices and open communication, and learning from our experience to continuously improve patient safety and quality.'

The only way this can happen is if doctors are not unfairly penalised for genuine mistakes.

Who among us has never made a mistake? Doctors too are human, and it is unrealistic to expect them never to make errors.

That is why it is important that system checks are in place as a safety net to catch mistakes. Some of the new measures may seem cumbersome. But there should be no complaints, because they are there to protect not just the patient, but also the doctor and pharmacist.

Singapore has a great public health system. Far from perfect, but constantly improving. And it is this willingness to admit mistakes and to learn from them that has led to better patient care.

As patients, that is all we can ask for.