Source · Prevention of Future Deaths
John Skinner
Ref: 2022-0041
Date: 10 Feb 2022
Coroner: Graham Danbury
Area: Hertfordshire
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryA junior doctor misheard a senior colleague's verbal instruction for phenytoin dosage, leading to a significant overdose. The coroner noted the risk of confusion from similar-sounding numbers in verbal communication within hospitals.
Date
10 Feb 2022
56-day deadline
12 Apr 2022
stated in the report
Responses identified
0 of 1
Coroner's concerns
A junior doctor misheard a senior colleague's verbal instruction for phenytoin dosage, leading to a significant overdose. The coroner noted the risk of confusion from similar-sounding numbers in verbal communication within hospitals.
View full coroner's concerns
(1) The Junior doctor Instructed to administer phenytoln did not know the required dosage and asked his more senior colleague for advice. The senior doctor's reply 15kmg/kg was heard by the Junior doctor as 50mg/kg resulting in administration of a significant overdose. This Is a readily foreseeable confusion which could apply in any hospital and could be avoided by use of clearer and less confusable means of communication and expression of number
Report sections
Investigation and inquest
On 18 May 2020 I commenced an Investigation Into the death of John Paul SKINNER. The Investigation concluded at the end of the Inquest on 4 November 2021. The conclusion of the Inquest was Mr Skinner was admitted to Watford General Hospttal suffering tonic clonlc seaures. The doctors caring for him decided to administer Phenytoln, an anti-epileptic medication. The Junior doctor Instructed to administer the drug sought advice from a more senior doctor as to the dose to be administered. As a result of a failure In verbal communication between the doctors, aggravated as both were masked, a dose of 15 mg/kg was heard as 50 mg/kg and an overdose was administered. 1 a Acute Csrdlac Failure 1 b Phenytoln Toxicity 1c II Chronic lachaemlc Heart Disease, Urolithlasis
Circumstances of the death
. On the 15th May 2020 John Skinner was admitted to Watford Hoapltal suffartng from a tonic clonlc seizure he had a background of cannabis usage and a subdural empyema In 201 Othat had left him with epilepsy. On arrival at hospital he again had another tonic clonlc seizure and focal seizures. He was given 3600 mg of phenytoln. He arrested within 16 minutes and died and could not be revived.
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Report details
- Reference
- 2022-0041
- Date of report
- 10 February 2022
- Coroner
- Graham Danbury
- Coroner area
- Hertfordshire
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 Apr 2022 (stated in the report).
Sent to
- NHS England