Kathleen Ludmila Neville · Prevention of Future Deaths report

On 6 March 2014 I commenced an investigation into the death of Kathleen Ludmila Neville, aged 93. The investigation concluded at the end of the inquest on 30th July 2015. The medical cause of death was: 1A Bilateral Pneumonia and 1B Fractured neck of femur (operated). I gave a narrative conclusion as follows “Kathleen Ludmila Neville died from the recognised complications of necessary medical intervention and post-operative care, following a prolonged hospital stay after accidentally fracturing her hip and undergoing a left hip hemiarthroplasty.”

Kathleen Ludmila Neville was admitted to University Hospital of Wales Cardiff on 28th November 2013 after an accidental fall at home in which she had fractured the neck of her femur. The admitting doctor failed to record her regular thyroid medication (Levothyroxine) on the drug chart and the error was not picked up in the primary pharmacy review. The University Hospital of Wales did not have a Medication Reconciliation Policy in place at the time, even though the NICE guidelines from 2007 had recommended such a policy. As a result of this prescription error Kathleen Neville was not given her thyroid medication for a period of five weeks from admission until 8th January 2014. I found that the omission of this medication would have contributed to her lassitude and confusion over the period from 12th December 2013 until 22nd January 2014, but that it did not contribute to her eventual death on the 3rd March 2014.

(1) The absence of a Medication Reconciliation Policy at the University Hospital of Wales over the relevant period made it much harder for the individual failures of the admitting doctor and initial pharmacist to be picked up. As a consequence Kathleen Neville was deprived of her medication for a much longer period than would otherwise have been the case.
(2) While the Coroner found in this inquest that the omission of Levothyroxine did not contribute to the eventual outcome, the position would have been far different in the case of other drugs where omission of medication might lead directly to death (e.g. in insulin). In such cases the absence of a Medication Reconciliation Policy assist in picking up individual failures could lead to future deaths. The Coroner found that any system that relies solely on individual human excellence without a supporting policy is eventually bound to fail through individual human error.
(3) The Cardiff & Vale University Health Board has now introduced a Medication Reconciliation Policy as recommended by the NICE Guidelines (now updated). The Coroner was satisfied that this was chiefly because of the death of Kathleen Neville. The Coroner was satisfied that University Hospital of Wales and the Cardiff & Vale University Health Board has taken appropriate remedial action.
(4) The Coroner is concerned that there may be other Health Boards across Wales that have still not adopted a Medication Reconciliation Policy as recommended by NICE. Future lives may be lost if a Health Board does not have such a policy and similar prescription errors are made. The Coroner is concerned that all Health Boards across Wales should learn the lessons of this inquest and have a Medication Reconciliation Policy in place to prevent future deaths in similar circumstances.