Irene Whittingham · Prevention of Future Deaths report

On the 09 August 2019, I commenced an Investigation into the death of Irene Whittingham, born on the 24th November 1932. The Investigation concluded at the end of the Inquest on the 21 February 2019.

The medical cause of death was: -

1a) Bilateral Hypostatic Pneumonia
1b) Multi Organ Failure
1c) Hypercalcaemia due to Vitamin D Toxicity

II) Hyperparathyroidism, Ischaemic Heart Disease and Nephrosclerosis

The Inquest conclusion was Accident contributed to by Neglect.

The deceased died at The Royal Bolton Hospital on the 31st July 2019 from the toxic effects of a Vitamin D overdose.

The deceased suffered from a number of medical illnesses, including liver and kidney disease, hyperparathyroidism with Vitamin D malabsorption, small vessel disease and hypertension for which she was receiving treatment for these conditions.

On or around the 22nd March 2019, the deceased was admitted to hospital with seizures and it was clinically suspected that the cause was due to a cerebral event. Investigations also revealed low Vitamin D levels and advice was sought from a Specialist who recommended 20,000 international units of Vitamin D to be given twice a week for 3 months. In error, the discharge summary incorrectly recorded the Vitamin D to be given once a week. The ward pharmacist picked up the error but incorrectly amended the discharge summary for the medication to be given twice daily. No advice was given about monitoring the deceased’s blood levels whilst she was being loaded on a high dose of Vitamin D which exceeded the national guidelines.

The deceased was deemed fit for discharge on the 12th April 2019 and her prescription was dispensed in the community.

On the 10th June 2019, the deceased was readmitted back to hospital and treated for acute kidney injury and Vitamin D toxicity. The deceased's condition did not improve and she died on the above date.

During the Inquest, evidence was heard that: -

1. Conflicting guidance is provided to treating clinicians as to when Vitamin D and Calcium blood level monitoring should be undertaken especially in patients who are given higher (loading) doses of Vitamin D, which exceeds the recommended national guidelines. The Consultant in Acute Adult Medicine gave evidence that the expected blood level monitoring to have taken place within 4 weeks of the loaded Vitamin D commencing, whereas the Endocrinologist, gave evidence that he expected the blood level monitoring to take place around the 3 month period elapsed the course of medication had been completed. In any event, no advice or instructions were issued to the deceased GP, regarding any requirement to monitor the deceased blood levels whilst she was in the community and taking high levels of Vitamin D which exceeded national guidelines.

2. I request that The Chief Executive of The Royal Bolton Hospital reviews:

i. The guidance and practices being adopted by staff, in regard to when blood monitoring of the above types of patients should take place to ensure a consistent and safe approach is adopted.

3. The WellSky and EMIS Software, had a confusing user drop down menu option, which allowed the user to click on a twice daily dose despite the loaded dosage, exceeding national guidelines.

4. I request that The Chief Executives of WellSky and EMIS Software company reviews:

5. The dropdown user options to ensure better system safety nets are put in place to prevent catastrophic prescribing errors occurring in the future