Jennifer Ann Midgley · Prevention of Future Deaths report

On the 27th September 2016 I commenced an Investigation into the death of Jennifer Ann Midgley, aged 65. The Investigation concluded at the end of the Inquest on 26th September 2017. The conclusion of the Inquest was in narrative form, a copy of which is attached hereto, including the medical cause of death of:-

1(a) Multi-organ Failure associated with Acute On Chronic Liver Failure
1(b) Paracetamol Toxicity on the background of Non-alcoholic Fatty Liver Disease with Cirrhosis
1(c) Fracture of the Left Femur (Operated 24/09/2016)
2 Malnutrition associated with Severe Chronic Obstructive Pulmonary Disease

Jennifer Ann Midgley suffered with chronic obstructive pulmonary disease which had caused her to become malnourished and underweight. This caused her to have non-alcoholic fatty liver disease with cirrhosis. On 22nd September 2016 she fell at her home, fracturing her left neck of femur which was surgically repaired at Pinderfields Hospital, Wakefield on 24th September 2016. Post-operatively she was prescribed paracetamol for pain relief. This was administered both orally and intravenously. When administered intravenously the dosage should be adjusted to compensate for the patient's weight. Mrs Midgley was given at least one dose of paracetamol intravenously which was not calculated according to weight and was therefore an overdose, causing her to develop organ failure as a contributory factor in her death.

(1) I was informed that the drug administration chart does not clearly distinguish between the administration of oral and intravenous paracetamol, nor does it have any reference to a patient's weight in respect of intravenous administration.

(2) I recommend that the Trust's drug administration chart should be redesigned and include separate columns indicating oral and intravenous administration of paracetamol.

(3) When paracetamol is administered intravenously there should be a reference on the chart to the patient's weight, and also a reference as a reminder that intravenous dosage of paracetamol should be modified according to the patient's weight.