Pensioner Dies After Receiving ‘Double’ Drugs Dose - Coroner Records Natural Causes Verdict

Medical Law Experts Call For Lessons To Be Learnt


An inquest has heard how a Somerset pensioner died five weeks after being given double the prescribed dose of a drug dispensed by a Boots pharmacist.

Medical law experts from Irwin Mitchell solicitors are now calling for Boots to prove it has learnt lessons across its entire chain of pharmacy outlets to protect patients in the future.

Recording a verdict of Natural Causes, HM Assistant Deputy Coroner, Terence Moore, for the District of Avon, heard that 80-year-old Ellen Newman from Weston Super Mare, was a resident at a local retirement home and had been prescribed the drug Primidone by her GP, to control tremors.
However, a tablet containing double the prescribed dose was dispensed by the Weston Super Mare High Street branch of Boots. As care homes are legally not allowed to halve tablets they returned them to the pharmacy. However, later that day the tablets were sent back to the home with instructions from the pharmacist that it was in fact okay to give a whole tablet.

The inquest heard that after taking the Primodone tablet, Mrs Newman, who was a resident at Earlfield Lodge Retirement Home in Weston Super Mare, became very lethargic, was unable to move her limbs, and developed slurred speech - all within an hour of the medication being given.

She was later transferred to Weston General Hospital, suffering from kidney and liver failure.  Mrs Newman remained in hospital and, following respiratory failure and other complications including serious liver damage, sadly she passed away five weeks later, on 23rd June 2010.

Gillian Tayler, a medical law expert with Irwin Mitchell Solicitors, who is representing the family, said: “The overdose that Ellen Newman was given should never have happened. The inquest investigation revealed that there was confused communication between the GP surgery, the pharmacy and the care home that led to the wrong dose being given.

“Although the post mortem indicated that ultimately Mrs Newman died as a result of natural causes*, the over-medication led to her condition deteriorating.

“As a result of this serious incident, Boots confirmed it has since made a number of staffing changes, but the family are anxious to ensure that lessons have been learned across its chain of pharmacy outlets so that critical errors like this are not allowed to happen in the future.

“Following today’s inquest, the family will be considering their next course of action including the possibility of legal action.”

Speaking on behalf of the family, daughter, Vanessa Newman, also from Weston super Mare, said: “The whole family has been devastated by the loss of our mother. Although she was being looked after in a retirement home because she had difficulty walking unaided, she had a good quality of life.
“I am convinced that she would have lived longer had it not been for that prescription error. People put their trust in pharmacists to get things right. I just hope that, if nothing else, Mum’s death will lead to lessons being learned so that no other family has to go through the heartache we have suffered.”

Note to Editors:

* Cause of death listed as:
1. Respiratory failure
2. Pulmonary Oedema
3. Liver Cirrhosis