Woman, 65, died after pharmacy staff gave her the wrong prescription to treat shingles because box was incorrectly labelled, inquest hears
- Eileen McAdie, 65, prescribed an increased dose of Amitriptyline by her GP
- Staff at Village Pharmacy, New Ash Green, allegedly gave her box of Amlodipine
- The drug is used to treat high blood pressure, but label on box said Amitriptyline
- The 65-year-old died at Darent Valley Hospital, Dartford, after falling into a coma
A woman died after she was given the ‘wrong prescription’ to treat shingles because the box was incorrectly labelled, an inquest heard.
Eileen McAdie went to the pharmacy a week before her death to pick up a prescription of Amitriptyline after being told she could have an increased dose by her GP, Dr Julie Taylor, to deal with the pain from her condition, the hearing was told.
But staff at Village Pharmacy in New Ash Green Kent, allegedly gave the 65-year-old a box of Amlodipine, used for treating high blood pressure, but with an incorrectly printed label for Amitriptyline.
Mrs McAdie, 65, died at Darent Valley Hospital, in Dartford, Kent, on September 27 last year after falling into a coma.
Eileen McAdie, 65, died at Darent Valley Hospital, in Dartford, Kent, on September 27 last year after falling into a coma
Speaking on the second day of the hearing, Dr Shivan Kanani, who treated the patient at the hospital, said he noticed the wrong label on the box and that Mrs McAdie had an abnormally low blood pressure.
He said tests showed the patient’s blood pressure was 80 over 50, when a healthy person’s pressure would be between 120 to 180.
Mrs McAdie also took a mental awareness test, scoring 8/10, when most patients are expected to get 10/10.
Dr Kanani diagnosed that the patient had an acute kidney problem and pneumonia and gave her antibiotics. Mrs McAdie remained in hospital when he finished his shift at 9pm.
The next time he heard about Mrs McAdie was a couple of days later when he was informed she was in intensive care.
Jackie Giltrow and John McConnville, from the Royal Pharmaceutical Society were both called to give evidence during the hearing.
They spoke about the already known risk of ‘lookalike and soundalike’ drugs that staff are at risk of mixing up. Amitriptyline and Amlodipine were both high on this list of mix-up drugs.
Both witnesses were asked what has been done to stop this sort of tragedy happening again.
Mrs Giltrow mentioned a warning about these drugs was sent out in a monthly newsletter, just a couple of weeks prior to the incident.
But, when questioned by family barrister James Robottom, it was revealed the newsletter was read by pharmacist Mr Ghartey Reindorf, but not disseminated to other staff members at the Village Pharmacy.
Mr Ghartey Reindorf was later moved from the New Ash Green pharmacy to Chatham and Mr McConville revealed that when he was informed of Mrs McAdie’s death he was ‘devasted’ because he knew her as a regular customer.
The inquest continues