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Medical misadventure verdict at inquest of nursing home resident given accidental overdose

Antipsychotic medication among drugs erroneously given to John Mee (71) at Cahercalla Nursing Home in Co Clare

John Mee's sisters Bernadette Mee and Sr Gabriel Margaret Mee with Martin Kerrigan of Berwick Solicitors and Doireann O'Mahony BL at Kilmallock Courthouse. Photograph: Brendan Gleeson

David Raleigh
Wed Mar 6 2024 - 20:01

A verdict of medical misadventure has been recorded at an inquest into the death of a man who was given an accidental overdose of medication at a nursing home in Ennis, Co Clare.

Limerick Coroner John McNamara said the “medication error” by a nurse on duty at Cahercalla Nursing Home was a “catalyst” in the events that led to the death of John Mee on June 30th, 2021.

It was accepted by all parties at the inquest in Kilmallock Courthouse that the 71-year-old from Miltown Malbay was given another resident’s medication, including a high dose of an antipsychotic drug, in addition to his own medication.

The incident occurred at around 9pm on June 24th, 2021. However, the inquest heard Mr Mee was not taken to hospital for 18 hours despite being visibly drowsy.

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Collette Mannion, staff nurse at Cahercalla, told the hearing she mistakenly gave Mr Mee the medication at a time when the nursing home was “unusually busy”. She said she and one healthcare assistant were looking after 23 residents on St Joseph’s ward that night.

Having realised her mistake, Ms Mannion said she checked Mr Mee and then contacted a “senior response person”. She also contacted an out-of-hours GP service and was advised to carry out regular observational checks on Mr Mee.

John Mee (71), from Miltown Malbay, Co Clare, died after receiving an accidental overdose at Cahercalla Nursing Home

Asked if she was under pressure on the night, Ms Mannion said some of the residents were “restless” and were “pressing” alarms in their rooms, which staff were trying to answer “as promptly as we could”.

She said Mr Mee “looked quite drowsy”, which was not normal for him, but he was still “responsive” and appeared to be comfortable. It was accepted that possible side effects of the antipsychotic medication erroneously administered to Mr Mee included drowsiness and dizziness.

She said she would have called for an ambulance had Mr Mee’s oxygen levels dropped suddenly to critically low levels.

Ms Mannion said “extra checks” were now in place at the nursing home in respect of the administration of medication, which included a photograph of the resident beside their room number and medication chart.

Caoimhe Daly BL, for the nursing home, said Ms Mannion had “candidly accepted she had made an error”.

Maureen Hayward, a nurse who took over caring for Mr Mee the next morning, said he was “chesty” and “drowsy” when she checked on him. She said she became “concerned” at Mr Mee’s oxygen saturation levels and he was administered two litres of oxygen. She then phoned for an ambulance.

Ms Hayward said she could not say exactly when she contacted Mr Mee’s family, who complained that they were not notified until 15 hours after the medication error.

She said she had made “a mistake” when she included a drug that Mr Mee had not taken in a transfer letter sent with him to University Hospital Limerick (UHL).

Dr Sean Fennessy said Mr Mee was “in some respiratory distress” with a “chronic cough” and fluid in his lungs when placed in his care at UHL. He said Mr Mee’s condition worsened and he died on June 30th. He agreed that Mr Mee was an “unwell patient” by the time he got to the hospital.

Dr Gabor Laskai, who conducted a postmortem on Mr Mee, said the cause of death was haemorrhage following extreme pancreatitis, pneumonia and gastric stress erosions.

The coroner said it was clear the overdose was accidental but he could not exclude it as being a contributory factor to Mr Mee’s death. He said he was “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,” he said. “Clearly John had something else going on that maybe no one knew about, but nonetheless the overdose is a catalyst in the [overall] picture.”

Mr McNamara recommended that Cahercally Nursing Home “adopt best practices” in respect of the administration of medicines for residents, which he was told it has done already.

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