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Investigation and inquest
On 18 May 2020 I commenced an investigation into the death of John Paul SKINNER.
The Investigation concluded at the end of the Inquest on 4 November 2021.
The conclusion of the Inquest was Mr Skinner was admitted to Watford General Hospital suffering tonic clonic seizures. The doctors caring for him decided to administer Phenytoin, an anti-epileptic medication. The junior doctor instructed to administer the drug sought advice from a more senior doctor as to the dose to be administered. As a result of a failure in verbal communication between the doctors, aggravated as both were masked, a dose of 15 mg/kg was heard as 50 mg/kg and an overdose was administered.
1a Acute Cardiac Failure
1b Phenytoin Toxicity
1c
II Chronic Ischaemic Heart Disease, Urolithiasis
Circumstances of the death
On the 15th May 2020 John Skinner was admitted to Watford Hospital suffering from a tonic clonic seizure he had a background of cannabis usage and a subdural empyema In 2010 that had left him with epilepsy. On arrival at hospital he again had another tonic clonic seizure. He was given 3500 mg of phenytoin. He arrested within 15 minutes and died and could not be revived.
Coroner’s concerns
(1) The Junior doctor instructed to administer phenytoin did not know the required dosage and asked his more senior colleague for advice. The senior doctor's reply 15mk/kg was heard by the junior doctor as 50mg/kg resulting in administration of a significant overdose.
This is a readily foreseeable confusion which could apply in any hospital and could be avoided by use of clearer and less confusable
means of communication and expression of number
Information checked against the published report and official responses