Wrong medication factor in death of heart patient
A woman died two days after she was given the wrong medicine by her pharmacist, an inquest heard yesterday.
Margaret Swaine (63) died following a sudden heart attack on July 24th, 2010, two days after she was mistakenly given Tegretol, a strong anti-convulsant and mood stabilising drug.
Dublin city coroner Brian Farrell said her death was a result of her heart condition but that the effects of the drug had constituted an “additional stressor”. He returned a narrative verdict outlining the facts.
The court heard that Ms Swaine, a resident at Regina Coeli Hostel in Dublin 7, went to the Janet Dillon Pharmacy in Stoneybatter for a refill of her monthly prescription including blood circulation medication Trental on the morning of July 22nd.
When she returned home, a friend Ann Murphy checked the medication and saw that Ms Swaine had been given Tegretol but thought it had been prescribed for depression.
The deceased took the pill three times over the course of the day and became groggy, disorientated and unsteady on her feet. The following morning Ms Murphy went to the pharmacy to check the prescription’s strength and showed pharmacist Janet Dillon the box.
“She just said ‘Oh my God’ and asked me had I got the tablets, which I handed over to her. She gave me Margaret Swaine’s proper blood pressure tablets,” she said.
Ms Dillon told the court that Ms Swaine had been given Tegretol instead of Trental as a result of a “picking error” by a trainee pharmacist’s assistant. The pharmacist said she checked all medication before it was given to Ms Swaine but had failed to pick up on the mistake. She attributed this to “human error”.
Professor of clinical pharmacology at UCD Patrick Murray said Ms Swaine’s symptoms were at the “severe end” of the effects of taking Tegretol.
Patients are normally started on a lower dose. Ms Swaine had been taking full doses that day. He told the court he believed the stress caused as a result of the Tegretol’s effects was a contributing factor in Ms Swaine’s death.
“It is very unlikely that she would have passed away on that given day had she not taken the Tegretol,” he said.
The inquest heard that gardaí prepared a file for the DPP in relation to the matter who directed no prosecution.
Pathologist Niall Mulligan found the cause of death was a sudden heart attack, secondary to hypertensive heart disease, ischaemic heart disease and arrythmogenic right ventricular cardiomyopathy – a rare inherited heart muscle disease normally associated with sudden death in young people.
The Tegretol was slightly above therapeutic range but not toxic at death.