Dying patient twice given wrong dosage, inquest hears

A leading nursing home in Donegal has revised its practices following the death of an elderly patient who was given almost ten times her prescribed medication on two occasions.

Strict new measures have been implemented for staff at Larissa Lodge Nursing Home in Letterkenny following the death of Marie Glackin in 2020.

In 26 hours prior to her death, Ms Glackin was administered 10 milligrammes of OxyNorm having been prescribed doses of 1-2 milligrammes of the drug.

The 97-year-old, of Main Street, Dungloe, passed away on May 24, 2020.

An inquest into her death this week heard how nursing staff administered the wrong dosage due to a mix-up between milligrammes and millilitres.

The inquest, held by Donegal Coroner Dr Denis McCauley at Letterkenny courthouse on Wednesday, established that the error did not have ‘a material effect’ on the death of Ms Glackin, who was receiving palliative care at the time. 

Ms Glackin’s daughter, Maureen, was present at the inquest and indicated that she was happy with the level of care given to her late mother. 

However, arising out of the incidents, Larissa Lodge have taken a series of what they have called ‘operational learnings, evidence of which was given by Abhilash Pattathil, the person in charge of the facility.

All prescriptions are now done in milligrammes and one-millilitre syringes are used for the administration of controlled drugs.

New nurses at the nursing home have to undergo two competency assessments prior to commencing their medication rounds and must have medication management training.

The medication management system was received and a new electronic seems has been introduced in an attempt to minimise errors  

A weekly review of controlled drugs is carried out and medication audits are completed fortnightly. No similar errors have since been identified.  

“They recognised the processes afterwards to ensure that this error won’t happen again,” Dr McCauley said, thanking the nursing home for their assistance in the inquest.

Larissa Lodge Nursing Home

Ms Glackin was admitted to the nursing home from Letterkenny University Hospital for long-term care in March, 2020 having suffered a hip fracture two months previously.

Ms Glackin tested positive for Covid-19 on April 23, 2020 and was nursed in isolation. 

From May 14-18, 2020, Ms Glackin was in LUH for treatment of a respiratory infection.

Upon her return to Larissa Lodge on May 18, her general condition detonated. When advised that Ms Glackin would require palliative care, both she and her family expressed the wish to remain in the nursing home.

As she was hypersensitive to morphine, Ms Glackin was prescribed 1-2 milligrammes of OxyNorm every four-six hours and a nurse was assigned to be with her at all times, Mr Pattathil said.

On May 24, 2020, Ms Glackin passed away at 3.37pm, seven hours and 22 minutes after she was administered 10 milligrams of OxyNorm. 

At 1.20pm the previous day, Ms Glackin was also given 10 milligrams of OxyNorm. 

Once the error was noticed, it was reported to a senior member of staff. 

Dr McCauley said the mistake could be put down to ‘human error where milligrammes were confused with millilitres’.

Dr Denis McCauley

“The nursing home realised this very quickly, full disclosure happened quickly and this is to be commended,” Dr McCauley said. “There was a misunderstanding here. There has been a reinforcement of training since and auditing and reviewing are now in place.

“Unfortunately, a mistake happened, but immediately they got on board and recognised it and acted on it, which is the appropriate standard - which isn’t always achieved. In this case, it was achieved admirably.”

Pathologist Dr Gerry O’Dowd told how, based on the information he had gathered from a blood sample, he formed the open in that Ms Glackin had died of multi-organ failure, secondary to a recent bout of Covid-19.

Ms Glackin’s remains were brought back to Letterkenny University Hospital for tests, which showed the levels of OxyNorm.

The levels of OxyNorm in her system were, Dr O’Dowd explained, higher than therapeutic, but below toxic or lethal levels.

Dr O’Dowd said he did not believe that the excess administration of the drug had a material effect in terms of Ms Glackin’s death.

“The timeline is significant under normal circumstances,” he said. “OxyNorm reaches peak levels after three to four hours. It it was going to have had a major detrimental effect, you would expect death to have occurred earlier.”

Dr McCauley said that the erroneous administration of the drug did not ‘have any effect on the natural course of the condition’. 

The coroner found that Ms Glackin died of multi-organ failure as a result of persistent pneumonia and returned a verdict of death by natural causes.