Incorrect Prescription Led To Overdose

Clerical failures have been blamed for the death of a four-month-old baby girl who died after an incorrect prescription resulted in her suffering an overdose of the drug Frusemide.

Abbie Jones, who had Down's syndrome and a hole in her heart, suffered an overdose after an inaccurate prescription resulted in her receiving 10 times her normal dose of the drug.

The Sheffield inquest heard conflicting accounts of how the incorrect prescription was prepared by receptionist Julia Dransfield and signed by GP Dean Warwosz.

Coroner Chris Dorries said a failure to adhere to "established and recognised procedures" had resulted in the fatal error being made at the Sheffield Road surgery in Barnsley.

In a narrative verdict, Mr Dorries said: "The overdose arose because a prescription was wrongly issued on April 24 2006 which increased Abbie's medication tenfold.

"The prescription was wrongly generated on the surgery computer as a result of established or recognised procedures not being followed within the practice."

Mr Dorries said the exact circumstances in which the prescription was signed by a doctor "remain unclear" and has called on the chief medical officer to propose changes that would make it impossible for clerical staff to issue anything other than repeat prescriptions.

Copyright © Press Association 2010

Beth Reay, a clinical negligence lawyer from law firm Irwin Mitchell said: “This case demonstrates how serious the consequences of a prescription error can be. We act for a number of families who have lost a loved one as a result of failures to ensure that there are fail-safe systems in place to protect patients from basic prescription errors. We hope that the NHS can learn from tragedies like this one and review their systems for administration of drugs accordingly.”