A CORONER delivered a verdict of medical misadventure in the death of a man who was given an accidental overdose of another resident’s medication at a nursing home in County Clare.
Limerick Coroner John McNamara said the “medication error” by a nurse on duty at the Cahercalla Nursing Home in Ennis was a “catalyst” in the events that led to John Mee’s death on June 30, 2021, at University Hospital Limerick (UHL).
It was accepted by all parties Mr Mee (71) from Miltown Malbay, County Clare, was given another resident’s medication, including a high dose of anti-psychotic medication, in addition to Mr Mee’s own medication, which he was receiving for a number of co-morbidity issues.
The erroneous overdose of prescribed drugs occurred at the nursing home around 9pm on June 24th, 2021, however Mr Mee was not taken to hospital for 18 hours, despite being visibly drowsy.
Cahercalla staff nurse Collette Mannion told the inquest at Kilmallock Courthouse that she mistakenly gave Mr Mee some of his own medication together with high doses of drugs that were prescribed to another resident.
She said it was “unusually busy” at the nursing home on the night and that she and one healthcare assistant were looking after 23 residents on the St Joseph’s ward.
Ms Mannion said that upon realising her mistake she checked Mr Mee and then contacted a “senior response person”.
Ms Mannion also contacted the out of hours GP service Shannondoc and was advised to carry out regular observational checks on Mr Mee.
Asked by Ms O’Mahony if she had been under pressure on the night, Ms Mannion said some of the residents were “restless” and were pressing alarms in their rooms “which needed to be answered promptly and we were trying to answer them as promptly as we could”.
She said Mr Mee “looked quiet drowsy and that wasn’t normal for John”, but she said he was still “responsive” and he appeared to be comfortable throughout the night.
It was accepted that possible side-effects of the overdosed anti-psychotic medication that was erroneously administered to Mr Mee included drowsiness and dizziness.
Ms Mannion said Mr Mee’s “airway was not compromised” and he was “not in respiratory distress”. She said that had Mr Mee’s oxygen levels suddenly dropped to critically low levels “I would have rang for an ambulance”.
She said “extra checks” were now in place at the nursing home in respect of the administration of mediation to residents, which she said included a “photograph” of residents beside their room number and medication chart.
Caoimhe Daly BL, barrister representing Cahercalla nursing home said Ms Mannion had “candidly accepted she had made an error”.
Ms Mannion, answering Ms Daly, confirmed that out of five drugs that were meant for the other resident, which had been erroneously administered to Mr Mee, the deceased was also prescribed two of these drugs.
Maureen Hayward, a nurse who came on duty the following morning and took over caring for Mr Mee, said when she checked him he was “chesty” and “drowsy”.
Ms Hayward said she became “concerned” at Mr Mee’s oxygen saturation levels, which were then reading 85 per cent, and he was administered two litres of oxygen.
“I rang for an ambulance because I was concerned,” Ms Hayward said.
She said she could not say when she contacted Mr Mee’s family, who complained they were not contacted for 15 hours after the medication error.
Ms Hayward said she had made “a mistake” when she included a drug that Mr Mee had not taken in a transfer letter sent with Mr Mee to UHL.
UHL doctor Sean Fennessy said that when Mr Mee was placed in his care he was “in some respiratory distress” with a “chronic cough” and was diagnosed with fluid in his lungs.
Dr Fennessy said Mr Mee’s condition eventually worsened and he died at the hospital on June 30, he agreed with Ms O’Mahony that the man was an “unwell patient” by the time he got to UHL.
Dr Gabor Laskai, who conducted a post mortem on Mr Mee’s remains, said cause of death was due to haemorrhage following extreme pancreatitis, pneumonia, and gastric stress erosions.
Coroner John McNamara said that “cleary John had been overdosed accidentally”, adding that “I can’t not take the overdose as being a contributory factor to his death, ultimately. So on that basis I am satisfied that this is an appropriate case where I should record a verdict of medical misadventure.”
“I want to stress I am not ascribing blame to anybody. I am not allowed do so.”
“Clearly John had something else going on that maybe no one knew about, but nonetheless the overdose is a catalyst in the picture.”
Mr McNamara said the nursing home had introduced a new “traffic light system to try to prevent this eventuality happening again”.
He recommended Cahercalla “adopt best practices” in respect of the administration of medicines for residents, which he was told it has done.
