Sneh Lata Chaudhry · Prevention of Future Deaths report

On 22/10/2017 I commenced an investigation into the death of Sneh Lata Chaudhry aged 56 years. The investigation concluded at the end of the inquest on 04/06/2018. The conclusion of the inquest was Sneh Lata Chaudhry died from immediate complications following administration of an incorrect formulation of amphotericin. The Medical Cause of Death was 1a Hyperkalaemia following amphotericin administration 1b multiorgan failure following high risk coronary surgery 1c triple vessel ischaemic coronary disease ( off pump coronary artery bypass grafting 4/10/2017 II Diabetes mellitus, morbid obesity and asthma

Ms Sneh Latta Chaudhry had high risk coronary artery bypass grafting on the 4/10/2017 at Harefield Hospital with a prolonged stay in ITU. She developed a systemic candida infection. She required treatment with amphotericin. The wrong preparation of intravenous amphotericin was given (Fungizone rather than Ambisone). An HCA obtained the wrong preparation from the ward drug stock. The administering nurse and the checking nurse did not notice that the wrong preparation was obtained and then administered. The drug vials have a similar appearance.

(1) Fungizone and Ambisone have a similar drug vial appearance and can be confused. Fungizone is typically used as aerosol and Ambisone as an intravenous preparation. Fungizone has a smaller therapeutic window and is more toxic and may lead to a fatal hyperkalaemia as in this case.
(2) The nursing checks were described as passive rather than active