Prescribing error resulting in overdose led to Kingston Hospital patient’s death, inquest finds

Medical Background, Hospitalisation and Overdose Incident

Mr Chandrakant Patel, who suffered from Chronic Kidney Disease, had attended Kingston Hospital on the morning of October 27th, 2022, for a pre-planned appointment to carry out an assessment of his renal function.

He was then admitted to the Same Day Emergency Care Unit following a referral by the Renal Medicine Out-Patient Clinic amidst observations that he had become fatigued and less steady on his feet than he had been previously.

He was admitted overnight for monitoring and physiotherapy team review with an expectation that if his renal function remained stable, he would be discharged the following day.

However, at an inquest investigating the circumstances of his death which concluded earlier this month (May 3rd, 2024) at West London Coroner’s Court, evidence was heard that shortly before 10pm that night, Mr Patel was given an excessive 500mg dose of Pregabalin.

This was a drug he had been prescribed in the community for pain management, to be taken as needed. However, the dose he should have received was 50mg (ten times less). With his impaired kidney function, this meant he would take longer than a person with normal kidney function to secrete the medication.

Investigation and Findings

The error in dosage occurred due to the reliance placed by the prescribing doctor on a clinic letter produced following an appointment on 13th July 2022 which referred, incorrectly, to 'Pregabalin 500mg'.

This letter had been approved by a doctor in the Renal Medicine Outpatient Clinic, but an investigation carried out by the Trust following Mr Patel’s death found that the use of the clinic letter as a reference source was in breach of the hospital’s own Medicines Management Policy, as the clinic letter was dated more than 4 weeks prior to the admission.

It also found that there was a missed opportunity to review the medication doses given Mr Patel’s deterioration in renal function.

Medical Decline and Death

On 28th October 2022 Mr Patel's consciousness began to reduce and he suffered severe respiratory failure. He was urgently transferred to the Intensive Care Unit where he received treatment until he sadly passed away on December 8th.

Delivering her conclusion, Coroner Hannah Hinton attributed the cause of death to multiple organ failure, whilst adding that he had suffered ‘severe respiratory failure secondary to aspiration pneumonia and metabolic acidosis’, and that this had been ‘caused by the excess dose of Pregabalin’.

Legal and Family Response

Following Mr Patel’s death the family instructed medical law experts from law firm Simpson Millar to support them at the inquest, and to bring legal action against Kingston Hospital NHS Foundation Trust.

Speaking following the hearing their legal representative, Elizabeth Reid, raised concerns about the Trust’s failure to follow its own policies when administering medication, and with regards further evidence that came to light that nursing staff within the Trust had edited Mr Patel’s records both after the pregabalin dose was administered, and following his death.

In a statement issued on their behalf following the inquest the Patel family said: “Our beloved father was a cheerful, affectionate family man with a contagious laugh and a wonderful sense of humour. It's still unfathomable to us that he's been taken from us; it simply wasn't his time, and we struggle to accept how such a preventable mistake could claim his life in such a horrific manner. The 43 days he spent in the hospital were filled with immense suffering, and even now, we remain devastated and traumatised by the pain he endured and what we witnessed.

“We never imagined that our father wouldn't return home after what should have been a routine check-up in the capable hands of hospital staff. Hospitals are meant to be places of healing, but in our case, it was the opposite. The entire experience feels surreal, like a nightmare turned reality.

“He was at the mercy of individuals who made grave errors, took bad decisions, displaying shocking behaviour and a dismissive attitude. Witnessing the brokenness of the NHS system and the lack of accountability has left us deeply shaken.

“We've been seeking answers and were hopeful that the inquest hearing would offer us some clarity. However, a year and a half later we are still unclear. Observing the shortcomings within the NHS system and the absence of accountability has been deeply disheartening for us.”

The family’s legal representative, Elizabeth Reid from Simpson Millar, added: “The Inquest process has been very difficult for Mr Patel’s family, and hearing evidence about the numerous failures which occurred has been devastating for them. 

“While the Trust had policies in place to govern medication management, dosage, and administration, these were not adhered to by several members of staff, and Mr Patel tragically lost his life as a result.

“We are also particularly concerned that nursing staff within the Trust edited Mr Patel’s records after the pregabalin dose was administered and following his death. This is unacceptable, and we invite the Nursing and Midwifery Council to investigate this further.

“We are grateful to Mr Patel’s family for their perseverance during this process, and to Ms Emily Campbell of Serjeant’s Inn Chambers for her advocacy at the Inquest.”

Mr Patel is survived by his widow, Kailasben, as well as his three children.