Wrong medication but no neglect

A CORONER has ruled out neglect as the cause of an elderly patient’s death the morning after being given the wrong medicine.

An inquest heard yesterday how Leslie Phillips (85), a retired accountant of Thornley Crescent, Grotton, was admitted to the Royal Oldham Hospital on May 22 with respiratory problems.

Mr Phillips had been severely out of breath when seen by his nephew a few days earlier.

On the evening of May 23 a nurse incorrectly gave Mr Phillips a 15mg dose of nitrazepam, often used to treat short-term sleep problems. A recommended dose for Mr Phillips would have 2.25-5mg.

Mr Phillips later lost consciousness and the nurse admitted his mistake after misreading the patient’s notes.

The doctor ordered hourly checks on Mr Phillips, who early next morning was given an antidote to nitrazepam. He failed to wake and died at 9.20am.

The experienced nurse hadn’t been involved in any similar incidents and had admitted his mistake immediately, and the hospital trust decided not to take disciplinary action against him. An electronic system now prevents errors caused by handwritten notes.

Dr Alan Padwell, who carried out the post mortem, said Mr Phillips’ had a “slightly heavy” heart and a congested left lung. The 15mg dosage, he said, “would have been harmful. It may well have been the straw that broke the camel’s back.”

Coroner Simon Nelson concluded there hadn’t been gross error on the hospital’s part and recorded death as due to respiratory failure and pulmonary fibrosis and emphysema, with the nitrazepam a secondary, toxic factor.