Coroner criticises hospital over patient’s morphine death
CORONER CRITICISES HOSPITAL OVER PATIENT’S MORPHINE DEATH
A CORONER has criticised a hospital after a woman died when she was left unmonitored after being given three doses of morphine.
Louise Mckenzie, 28, a mother of 4 children under 10 was taken to King’s Mill Hospital in Mansfield, Nottinghamshire on 5 August 2007.
Medical experts told the inquest at Nottingham Coroner’s Court that the doses she was given although substantial were within normal levels but that she should have been monitored more closely.
Louise had been taken for a CT scan by a nurse and a care assistant but was left for at least 11 minutes unmonitored either visually or by machine in spite of the large amount of morphine she had been given and the fact that her oxygen saturation level had dropped dangerously low to 94%.
During the CT scan she stopped breathing and her brain was deprived of oxygen. Doctors at King’s Mill did not realise that she was already brain dead when they transferred her to the Queens Medical Centre Nottingham later that night where her death was certified after her organs had been donated by her family.
The Nottinghamshire Coroner Dr Nigel Chapman delivered a narrative verdict describing the events which led up to her death. He said the issue of monitoring patients after morphine was given at King’s Mill needed to be addressed. The lack of training of the staff concerned “beggared belief”. He would be writing to the hospital with his concerns.
Speaking after the verdict Louise’s husband Mark said: “I am very happy with the verdict and very relieved it is all over. Louise was the most loving, caring person with four young children who did not deserve to be treated the way she was.”
Now that the inquest was over his solicitor, Paul Balen of Freeth Cartwright, said that he hoped that the hospital would quickly admit legal liability and open negotiations with him over the payment of compensation to Mr Mckenzie who had been left alone to bring up the children.
ends - 2 August 2010
Notes for Editors
1. Mark and Louise Mckenzie were originally from Nottingham but had moved to Abergaveney, Gwent in search of a better quality of life for their 4 children. Their youngest child was 1 at the time of his mother’s death, the eldest was just 9.
2. On the evening of the 3rd August 2007 Mrs McKenzie had been out drinking with a friend from the deaf school she had attended in Nottingham to where she had returned from her home in Wales for the reunion.
3. She returned to her grandmother’s house in Nottingham after her night out and complained of a severe headache.
4. When the headache did not clear an ambulance was called. Mrs McKenzie was given paracetamol and 10 mg of oral morphine.
5. At 17.15 4 August 2007 she arrived at King’s Mill Hospital.
6. At 17:30 she was given 10mg of morphine.
7 At 18:10 a further 10mg dose of morphine was given.
12. At 18:15 nursing observations taken 5 minutes after the 3rd dose of morphine showed low oxygen levels (94%).
13. At 18:30 Mrs McKenzie was transferred to the CT scanner with a nurse escort and carer.
14. At 18:50 an emergency telephone call was made from the CT scanner indicating that Mrs McKenzie was in respiratory arrest requiring airway & breathing support. Mrs McKenzie was cyanosed (blue) and not breathing.
15 The CT scanner is some times referred to as the “donut of death”. Patients who have received potent pain killers are placed in the quiet isolation of the scanner without monitoring and obstruct their airways. Scenarios such as this are used by many to teach junior doctors how pain killers work, their side effects and the need for monitoring and good examples of risk management. It is basic medical knowledge and practice which was not followed in this case. It was negligent to fail to do so.
16. When Mrs McKenzie was placed in the scanner she was remote from the nurse charged with monitoring her. Monitoring in the form of blood oxygen levels and or carbon dioxide measuring should have been instituted to provide early warning that her breathing and her airway were becoming impaired. The nurses observing her in the scanning room should have had visual and audible access to the monitor if she could not be seen or heard. Instead of watching the patient the nurses apparently watched the CT scan monitor. They could not in any event see the patient and should have been observing monitors displaying her oxygen and carbon dioxide measurements had they been used.
17. When Mrs McKenzie was eventually seen to have turned blue the nurse and radiographer attempted to call the crash team. The voice recognition system did not work. The pull cord did not work. There was a delay until the crash team could be summoned.
18 The brain is the most sensitive organ in the body with regard to its oxygen requirements. It can only last in the region of 4-5 minutes if it becomes starved of oxygen. As a result of stopping breathing the ensuing oxygen starvation results in irreversible brain damage.
19. Morphine is an extremely powerful drug given to relieve pain. However, like all drugs it has unwanted side effects some of which are potentially lethal.
20. As a result of being dispensed morphine Mrs McKenzie became drowsy, begin to breathe slowly and probably because she was placed on her back her airway became obstructed and she “swallowed her tongue”. As a result she was unable to breath and became starved of oxygen. This resulted in brain damage.
21. Application of simple oxygen and/or carbon dioxide monitoring would have provided an early warning allowing the attending radiographer and nurses to intervene. The nurses gave evidence at the inquest that they were unaware of the requirement to monitor morphine patients closely and did not receive training. One said that he learnt by observing other nurses. There appeared to be no hospital protocols for observing patients who had been prescribed morphine.
22. Mrs McKenzie would have survived if the arrest in the CT scanner had not occurred
Further events:
23. It is probable that Mrs McKenzie died around 20:00 hrs on 4th August. Unaccountably the medical staff failed to realise this.
24 At 21:45 a lumbar puncture was carried out. If Mrs McKenzie was not already dead the release of pressure caused by the lumbar puncture would have caused coning of her brain and death.
25. The medical staff still apparently failed to realise that Mrs McKenzie was brain stem dead. Her husband and other relatives were told that she would recover. She was transferred to the Queens Medical Centre University Hospital Nottingham as there was no intensive care bed available at King’s Mill. On receipt it was obvious to the QMC medical staff that they had been sent a patient who was brain stem dead.
26 A senior doctor from the QMC told the inquest that this revelation clearly came to a bombshell to the family who had been led to believe by the doctors at King’s Mill that she would recover after 2 days on a ventilator.
27 The Coroner’s narrative verdict was as attached.
For more information contact:
Paul Balen
Freeth Cartwright LLP
0845 050 3289
07767673200
paul.balen@freethcartwright.co.uk
NARRATIVE VERDICT
NOTTINGHAM CORONER’S COURT
DR NIGEL CHAPMAN
30 JULY 2010
On Saturday 4 August 2007 Louise Mckenzie was admitted to King’s Mill Hospital with severe headaches. Louise was given Oramorphine by the Paramedic and then two doses intravenously equivalent to 20mgs of morphine to settle her in preparation for a CT Scan. Observations taken at 18.15 showed oxygen saturation to be significantly lower than would have been expected.
There was a failure to recognise the importance of this result which was reported as “normal”. She was transferred to the CT Scanner. The staff accompanying her failed to monitor her visually or by machine. Louise was left unmonitored.
She suffered a respiratory arrest as a result of the effect of the Morphine. This led to hypoxic brain injury and brain stem death which was recognised when she was transferred to the Queens Medical Centre, where her death was certified.