Grandmother died after she was given eight times the recommended dosage of blood pressure medication mistakenly, inquest hears

Bernie Kinsella (92) from Skerries, Co Dublin, died on August 2, 2021 at Beaumont Hospital in Dublin after suffering “profound hypotension” (low blood pressure) from an overdose of a prescribed drug.

A sitting of Dublin District Coroner’s Court heard the married mother of four who came originally from Coole, Castlepollard, Co Westmeath, was given 80mg of lercanidipine – a drug to lower blood pressure – on July 20, 2021 instead of the recommended dose of 10mg.

Evidence was heard that a junior doctor had erroneously listed 80mg as the recommended dose for the patient on medical charts, despite being given details of the correct dose by her family.

Today’s News in 90 Seconds – June 7th 2024

The inquest heard that there had been another error in the hospital records about the dosage of a second medicine prescribed to Ms Kinsella.

Asked by the coroner, Clare Keane, about the frequency of medication errors at the hospital, a senior clinical pharmacist at Beaumont, Ciara Reddy, replied: “Quite common, unfortunately.”

However, Ms Reddy said most errors were recognised quite quickly and she stressed that the number of mistakes that were likely to cause significant harm to patients was “quite small.”

The pharmacist accepted that lercanidipine was a high risk drug in case of an overdose as it could cause “significant harm.”

She told the inquest that unsuccessful efforts were made to empty the patient’s stomach before she was given charcoal about 75 minutes after the overdose to reverse its effect.

However, Ms Kinsella’s blood pressure continued to drop and she was transferred to a coronary care unit.

Ms Reddy, who observed there was a problem with understaffing at the hospital, said the medication of 85pc of patients at Beaumont was now reviewed within 48 hours of admission.

Had she seen the patient’s charts at the time, Ms Reddy said she would have known that the 80mg dose was “exceptionally unusual.”

Ms Kinsella’s daughter, Mary Kenny, told the hearing that her mother was brought to the emergency department at Beaumont on July 18, 2021 because she had appeared short of breath.

Ms Kenny gave evidence that her mother had otherwise been in relatively good health and was “very active at home.”

She recalled her mother was “happy and content” and well-cared for by her family as well as someone who had actively played golf up to her late 80s.

Ms Kinsella was married to retired golf professional, Jimmy Kinsella, and the couple were the subject of a book, Links of Love: How Golf Brought Jimmy and Bernie Kinsella Together, published earlier this year by golf writer, Dermot Gilleece.

Ms Kenny described how her mother was initially expected to be discharged from Beaumont after just a day or two.

The witness said she was concerned at one stage why her family were getting “VIP treatment” from hospital staff before being informed the following day that her mother had mistakenly been given an overdose of her medication.

Ms Kenny told the coroner that her family understood that an external review carried out into the circumstances of her mother’s death had made a number of recommendations which they hoped would be followed through on.

“We don’t want another family to go through what Mammy had to go through. It’s not an experience I’d wish on anybody,” said Ms Kenny.

She welcomed an update provided by counsel for Beaumont Hospital, Simon Mills SC, that progress on implementation of the recommendations was being made.

Another daughter of the deceased, Bernadette Kinsella, outlined how her mother had appeared to be doing well at various stages while in hospital before her condition would deteriorate again.

Ms Kinsella recalled at one stage how her mother had been looking for “whiskey and spuds” during her stay.

However, she also noted that her mother had remarked shortly before her death: “Why do I have to suffer like this? I’m going to die.”

A consultant at Beaumont, Imran Sulaiman, acknowledged that the patient was “making progress” prior to being given the wrong dose of medicine.

In response to questions from Dr Keane, he said hospital staff should always ensure that patients were given the correct dosage of medicines at the correct frequencies.

However, he admitted there was no straightforward answer as to who was ultimately responsible for medications given to a patient.

While there is no policy at Beaumont about reviewing a patient’s medication, Prof Sulaiman said the working practice is that it is done daily.

Under cross-examination by counsel for the deceased’s family, Caroline McGrath BL, the consultant acknowledged it had been established an unnamed senior house officer had overwritten the correct 10mg dosage of lercanidipine on medical charts with 80mg.

He also accepted that Ms Kinsella had not been given the drug on July 19, 2021 as someone had changed her chart to recommend that it should be given in the morning instead of at nighttime.

Prof Sulaiman agreed with the coroner that it should have been “absolutely evident” to the doctor who had changed the timing that the 80mg dose was incorrect.

The inquest heard the consultant is leading a programme to move Beaumont towards a system of e-prescribing with all medication records of patients being digitised.

He claimed the new system would have the potential to prevent overdoses of medicines being given to patients.

However, Prof Sulaiman claimed there were a number of obstacles to implementation of the system, including funding.

Nevertheless, he expressed hope that it would be operational in May 2025 and would “reduce the chance of you prescribing 80mg instead of 10mg.”

A staff nurse, Nimmy Matthews, told the inquest she had twice sought a pharmacal review about the dose of a different medicine prescribed for Ms Kinsella because of her concerns it was wrong before she administered 80mg to the patient on the morning of July 20, 2021.

The inquest heard Ms Matthews immediately alerted doctors after Ms Kinsella’s condition deteriorated after the overdose.

The nurse said she was familiar with the medication and its regular doses of 10mg and 20mg tablets but was unaware of any maximum dosage level.

She could not recall if the patient had asked anything about having to take eight tablets at the time.

Asked if she had considered holding off on giving Ms Kinsella such a quantity of lercanidipine, Ms Matthews replied that she was “just a nurse” and that she believed pharmacists and the patient’s medical team had prescribed the correct dose.

The nurse also observed that Ms Kinsella had not been given the drug at all the previous day.

Ms McGrath said the deceased’s family took some comfort from the fact that changes were being made in Beaumont following Ms Kinsella’s death.

However, the barrister said condolences offered by the hospital would only be meaningful if systemic issues were addressed including end-of-life care and treatment of families in such circumstances.

A postmortem confirmed that Ms Kinsella died from multi-organ failure due to hypovolemic shock because of an overdose of lercanidipine.

Dr Keane said severe coronary artery disease found in the patient was also a contributory factor.

Returning a verdict of medical misadventure, the coroner said she “wholeheartedly” endorsed recommendations already made by a review team.

Dr Keane observed that every person responsible for giving medicine to a patient should consider that they have “completely responsibility” for it.