Fatal Accident Inquiry into the death of Danielle Welsh

A Fatal Accident Inquiry into the death of Danielle Welsh at the Southern General Hospital on the 24 June 2008 concluded that she died from liver failure due to an overdose of paracetamol.

Having heard evidence over a total of twelve days Sheriff Cubie found that the precautions whereby Danielle’s death could have been avoided were:

• If Dr Das had checked the British National Formulary before prescribing intravenous paracetamol for Danielle on the evening of 17 June 2008.

• If the nursing staff who administered intravenous paracetamol to Danielle between 17 and 20 June had checked that they knew the normal dosage of intravenous paracetamol to be administered, having regard to Danielle’s weight.

• If the Pharmacist Lesley Murray had checked the British National Formulary in respect of intravenous Paracetamol when reviewing Danielle’s drug Kardex in Ward 67.

From the evidence heard Sheriff Cubie found there was, at the time of the death, a prevailing culture of assumed familiarity with the administration of intravenous paracetamol, a familiarity derived from the common use of oral paracetamol. That assumed familiarity was misplaced.

The Sheriff found that there were no defects in the system of working which contributed to the death.

Background

Danielle was born on the 5 June 1989.  She had an undefined condition which gave rise to spondyloepiphyseal dysplasia, short stature, mild but longstanding learning difficulties, problems with hearing and chronic pain particularly in the limbs and joints. In June 2008 she weighed 35 kilogrammes.

Given Danielle’s age, the management of her case was in the process of being transferred form Royal Hospital for Sick Children at Yorkhill to the Southern General Hospital (SGH). She was waiting to be seen by the Pain Clinic at SGH.

Danielle became unwell on the 15 June and her parents took her to the SGH.

Tests carried out disclosed a raised white cell count which might point to infection. The presumptive diagnosis was addressed by the administration of anti-viral and antibiotic drugs.  Danielle was also prescribed 1g paracetamol “as required”.

On 17 June Danielle was noted to be vomiting by the evening. Oral administration of drugs was accordingly more difficult but she continued to be in pain.

Dr Das, a foundation year one doctor, was asked to prescribe pain relief and anti-emetic drugs. She had had no previous dealings with Danielle and she did not know her weight. She proceeded to prescribe on the basis that Danielle was an adult.  In the event, the dosage prescribed, 1g four times daily, was in excess of the appropriate dosage for someone of Danielle’s weight. She should have received 525mg per dosage.

On the 18 June the intravenous administration of paracetamol continued.

On 19 June Danielle’s Kardex was reviewed by Pharmacist Lesley Murray. She may not have seen Danielle in person but she did not alter the prescription. She did not know that the intravenous and oral dosages of Paracetamol were different. She assumed that they were the same. However, Danielle continued to be nauseous, undermining the utility of oral administration of paracetamol. The intravenous administration of paracetamol continued at 1g four times daily.

On 22 June blood tests showed grossly abnormal Liver Function. She was referred to a consultant who, at 23.25pm, referred her to the liver unit at Royal Infirmary of Edinburgh (RIE). There was considerable concern about Danielle’s fitness for transfer.

At 01.30 Danielle was transferred by ambulance to Surgical ITU with acutely deranged Liver Function tests with coagulopathy and raised paracetamol levels. Danielle was in a critical condition but was considered to be likely to survive.

On 24 June 2008 Danielle suffered a cardiac arrest. She was subject to intensive CPR for a period of 35 minutes. but then suffered another heart attack and was pronounced dead at 10.25 am.

Danielle was seen by 11 nurses and 12 different doctors and received 20 doses of paracetamol. The doctors were at all levels and not one of them noted the overdose.  No one had appreciated that the intravenous dosage had different parameters from the oral dosage.

What was clear from the Inquiry was that there was a gap in the knowledge of all those who prescribed, administered, reviewed and considered the intravenous paracetamol prescription.

The Sheriff concluded that there was no systemic failure identifiable from the evidence led. The was, however, a prevailing and pervasive failure to appreciate the particular peculiarities of the intravenous dosage of paracetamol, a lack of knowledge and experience shared by the 23 different professionals who dealt with Danielle.

While the three precautions identified are easy to determine with the benefit of hindsight; the accumulation of evidence demonstrated that no professional expressed any concern about the use, or dosage of the intravenous paracetamol. It is unfortunate to single out individual practitioners for attention when they acted intelligibly, if wrongly, given the state of knowledge which prevailed.

There was a prevailing attitude that paracetamol was so familiar that no further enquiry was required., Danielle’s presentation was unusual in terms of her weight in an adult hospital. These factors combined tragically so that she received an overdose on a sustained and regular basis, which led to her death.

The Sheriff further noted that with the tragic and momentous exception of the paracetamol overdose, Danielle received attentive, focused and appropriate care by all the staff throughout her stay in hospital.

The sheriff made no recommendations, although observations were made about the Kardex system which records some patient information, and the drugs administered to the patient


The full determination is now available at this location:  http://www.scotcourts.gov.uk/opinions/2011FAI7.html