A heartbroken family are still looking for answers as to how their much-loved daughter died in hospital after being overprescribed paracetamol.
Karen Mackrill, 50, passed away at Diana, Princess of Wales Hospital on March 11, 2018. Now, a coroner has requested statements from doctors and pharmacists involved in administering the painkillers at the Grimsby hospital as well as Scunthorpe General Hospital, Grimsby Live reports.
A post mortem examination found that the patient had a "concentration of paracetamol which is higher than expected," a pre-inquest hearing was told. Humberside Police launched an investigation into the overdose and the possibility of prosecution was considered, however the Crown Prosecution Service decided not to continue with action.
Assistant coroner, Marianne Johnson said she wanted to hear an explanation from the CPS why the prosecution was not continued. She said it is her duty to attempt to prevent further deaths in similar circumstances elsewhere in the NHS.
She told the hearing at Cleethorpes Town Hall: "This was not just one hospital. Karen was at one hospital and then transferred to another and this was not picked up at either hospital." She told a solicitor representing the Trust, which runs both Scunthorpe General and Diana, Princess of Wales hospitals she wanted to see what action plan has been put in place since the death over four years ago and whether that has been shared with other hospital trusts nationwide.
The assistant coroner said the patient was not eating properly on February 26 2018 and was taken to hospital in Scunthorpe. "She was over-prescribed paracetamol and that is what led to her death on March 11," she told.
Reports on standard operating procedures in both hospitals will be provided at the next hearing. Lindsey McNee, of DAC Beachcroft, Leeds-based solicitors, acting for Northern Lincolnshire and Goole Hospitals Foundation Trust was instructed to provide statements from the clinicians and four pharmacists involved in dispensing the painkiller.
Karen's sister Susan, who works at Diana, Princess of Wales Hospital, told the hearing: "It was obvious her death was untoward. At the time the staff were aware that she had gone into liver failure." She said the family were upset that they had "had to wait and wait."
"There was a full year before Covid when this could have been dealt with," she said. Karen's mother Laura also attended the hearing. Assistant coroner, Marianne Johnson gave an apology at the start of the hearing and said: "This was 2018. It is such a long time. There are no excuses.
"We had two years of pandemic and there has been a change in coroner. I have only recently been appointed. But over four years is far too long. I apologise for how long it has taken."
She said: "I want to know what has been done since Karen's death to prevent it happening again." The assistant coroner said she needed to know the names of the doctors and pharmacists involved and will hear from Rachel Greenbeck, the author of the Trust's serious incident report.
Mrs Johnson said: "I would like to know how the action plan is progressing and if there have been any other similar incidents and how it is working.
"I need to know how pharmacists dispense medication. At least six people were involved and everyone has failed to make sure the correct amount has been prescribed."
The sister told the hearing Karen was "tiny and only wore children-size clothing" and had previously only received child levels of paracetamol orally. The hearing was adjourned to a date in August and a full inquest will be held later.
Dr Peter Reading, Chief Executive of Northern Lincolnshire and Goole Hospitals Foundation Trust, said: “Once again I want to extend our deepest condolences to Karen’s family. Nothing we say can bring Karen back, but we have always acknowledged that we were at fault in this case.
"In addition to the Police investigation we carried out our own serious incident investigation into what happened and we identified a number of learning points. These have been shared not only across the Trust but across the country via the Healthcare Safety Investigation Branch at our request.
“We will continue to co-operate fully with the coroner and hope the inquest brings the family some closure.”
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