Inquest told woman given wrong dose of painkiller

THE FAMILY of a woman who was given the wrong dose of a painkilling medicine before she died were not told about the medical error until 12 days after the incident, a coroner’s court heard yesterday.

Elizabeth Craul (78) died less than an hour after being given an injection of 15mgs of the painkilling drug Oxycontin. Nurses who treated her admitted they interpreted a prescription note which meant to convey that the dose should be given over a 24-hour period, to instead mean that it should be given once every 24 hours.

Ms Craul from Manor Kilbride, Blessington, Co Wicklow, was terminally ill with ovarian cancer when she was admitted to Naas General Hospital on January 8th last year. She died five days later. Her daughter-in-law Siobhán Craul told Kildare Coroner’s Court that the manner in which the news of the medical error had been conveyed to the family was “devastating”, especially for Ms Craul’s husband of 49 years, Billy.

“Trying to cope with losing his wife was bad enough, but this was worse. If we had been told the news on the morning that it happened it would have been easier for us to come to terms with,” she said.

Ms Craul said her mother-in-law had been subject to a poor level of care in the HSE and had been misdiagnosed for 18 months. “Had she been diagnosed properly she would still be here today,” she said.

However, Ms Craul’s husband said the staff at the hospital had been excellent and he did not blame the nurses involved. “It was a mistake and we all make mistakes. I wouldn’t want them to carry it around with them for the rest of their lives,” he said.

Kildare county coroner Dr Denis Cusack recorded that Ms Craul died of natural causes as a result of the cancer.

Consultant Dr Dermot O’Shea, who reviewed the case notes, said he believed Ms Craul had died from the cancer and from complications surrounding it, including a chest infection and pneumonia and that the drug which was administered to her did not cause her death because her body had been used to high doses.

The hospital’s director of nursing services Barbara Fitzgerald admitted that the use of the number one with a dot on top signifying once every 24 hours and 24 with a dot on top meaning the dose should be given over a 24 hour period was “very confusing” and “ambiguous to say the least” and was not recommended prescribing practice as set out in a HSE set of guidelines issued in 2007.

Dr Cusack said it was a “matter of fact” that a medication error had occurred, but he was satisfied that it was a combination of factors as a direct result of the cancer that were the cause of death.