Epileptic died after drug dose mistake

A Dublin nursing home gave a woman half her daily dose of a drug prescribed to help stabilise her epilepsy due to a charting error, an inquest has heard.

Kathleen Leech (68) from Courtown, Gorey, Co Wexford, died at Tallaght hospital on June 30th last year. Her death was not reported to the coroner’s office and no post mortem had been carried out,

Dublin City Coroner Dr Brian Farrell gave the cause of death based on the clinical evidence as aspirational pneumonia due to status epilepticus as a consequence of a previous stroke.

The reduced dosage of Keppra due to a "charting error" was a "possible causal or risk factor in the deterioration of her epilepsy together with a recent lower respiratory tract infection and previous stroke".

Seizures

He returned a narrative verdict outlining the facts and will write to the HSE urging progress on the development of a national prescription chart.

Consultant neurologist Dr Sinead Murphy told the court that Mrs Leech’s condition deteriorated in the nursing home and her seizures became more frequent and prolonged. She was transferred back to Tallaght Hospital on June 23th with partial status epilepticus and shortly after doctors discovered she was being given half the prescribed dose of Keppra while in the nursing home. Her condition continued to deteriorate until her death a week later.

The court heard the error arose because timings for drug administration are done by doctors in Peamount Healthcare unlike Tallaght Hospital where nurses do it. Doctors rotating between the two facilities were not aware of the differing policies.

'Betrayed and saddened'
The inquest was told by consultant physician at Tallaght Hospital and Peamount Healthcare Professor Desmond O'Neill that the first nurse who administered the drug at the nursing home had written down 9am and nobody reviewing Mrs Leech realised an evening dose was not being administered. He said Peamount Healthcare is "completely open" that the administration error should not have happened.

“Peamount is quite clear that it is sub-optimal care that a patient should not receive a twice daily dosage,” he said.

He called for a State-wide unified prescription chart to help eliminate errors.

Following the inquest, the dead woman’s daughter Noreen Leech said the family “feel betrayed and saddened as to how she was treated”.