By Woman died in hospital after being over-prescribed paracetamol
Four years after their daughter died in hospital after being over-prescribed paracetamol, a family are still searching for answers.
Karen Mackrill, 50, tragically died on March 11 2018 at the Grimsby hospital.
A coroner has asked for statements from the doctors and pharmacists involved in prescribing the pain killer at both Scunthorpe General Hospital and Diana, Princess of Wales Hospital in Grimsby.
The post-mortem revealed there was a “concentration of paracetamol which is higher than expected,” a pre-inquest hearing was told.
Humberside Police conducted an investigation into the overdose and considered the possibility of prosecution but the Crown Prosecution Service decided not to continue with action.
The assistant coroner said she wanted to hear an explanation from the CPS why the prosecution was not continued in an attempt to prevent similar deaths elsewhere in the NHS.
She told the hearing at Cleethorpes Town Hall: “This was not just one hospital. Karen was at one hospital and then transferred to another and this was not picked up at either hospital.” She told a solicitor representing the Trust, which runs both Scunthorpe General and Diana, Princess of Wales hospitals she wanted to see what action plan has been put in place since the death over four years ago and whether that has been shared with other hospital trusts nationwide.”
The hearing heard how the patient was not eating properly on February 26 2018 and was taken to hospital in Scunthorpe where she was over-prescribed paracetamol.
Reports on standard operating procedures in both hospitals will be provided at the next hearing.
DAC Beachcroft, Leeds-based solicitors acting for Northern Lincolnshire and Goole Hospitals Foundation Trust, have been instructed to provide statements from the clinicians and four pharmacists involved in dispensing the painkiller.
The assistant coroner gave an apology at the start of the hearing and said: “This was 2018. It is such a long time. There are no excuses. We had two years of pandemic and there has been a change in coroner. I have only recently been appointed. But over four years is far too long. I apologise for how long it has taken.”
She said: “I want to know what has been done since Karen’s death to prevent it happening again.” The assistant coroner said she needed to know the names of the doctors and pharmacists involved and will hear from Rachel Greenbeck, the author of the Trust’s serious incident report.
Mrs Johnson said: “I would like to know how the action plan is progressing and if there have been any other similar incidents and how it is working. I need to know how pharmacists dispense medication. At least six people were involved and everyone has failed to make sure the correct amount has been prescribed.”
The sister told the hearing Karen was “tiny and only wore children-size clothing” and had previously only received child levels of paracetamol orally.
The hearing was adjourned to a date in August and a full inquest will be held later.
