Barbara Joan COPE · Prevention of Future Deaths report

On 24 December 2025 I commenced an investigation into the death of Barbara Joan COPE.
The investigation concluded at the end of the inquest .

The conclusion of the inquest was Accident.

The cause of death was:

1a Multi-organ failure

1b Acute Liver Failure

1c Inadvertent Paracetamol Toxicity

II

This case relates to the death of a 75 year old woman who presented to Rotherham Hospital on the 11th June 2025 with decreased conscious levels, slurred speech and reduced oral intake. A stroke was ruled out and blood tests performed at 16:06 hours on the 12th June 2025, were undertaken to consider a unintentional staggered Paracetamol overdose. These tests were reported at 17:11 hours and confirmed a high level of paracetamol.

Despite clinical deterioration and two medical reviews overnight, these blood tests were not reviewed or acted upon until 10:00 hours on the 13th June 2025, delaying the administration of N-Acetylcysteine (NAC) until 12:30 hours, approximately 19 hours later after the results were available. Paracetamol excess requires time critical management to prevent further and irreversible damage to the liver.

(1) Although a blood sample was collected and tested in a timely manner, there was no evidence of communication and/or follow up of the abnormal result, therefore time critical medication was not commenced until 19 hours later.

(2) Even when the patient clinically deteriorated overnight and required two separate clinical reviews, the blood results were not reviewed and/or acted upon. If clinical records and recent investigations results are not reviewed then appropriate medical management will be delayed or will not occur.

(3) This patient was transferred from the emergency department to the care of Surgery. A referral was then made for Gastroenterology input, they then requested a blood test for paracetamol levels. This was not followed up for 17 hours. There needs to be clear communication, understanding and record keeping of who is responsible for patient and the ongoing follow up and care in these circumstances.