Source · Prevention of Future Deaths
Sneh Chaudhry
Ref: 2018-0182
Date: 15 Jun 2018
Coroner: Sean Cummings
Area: London (West)
Responses identified: 0 / 1
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Drug confusion due to similar vial appearance between Fungizone and Ambisone, combined with passive nursing checks, created a risk of administering the wrong, more toxic medication.
Date
15 Jun 2018
56-day deadline
2 Sep 2018 est.
Responses identified
0 of 1
Coroner's concerns
Drug confusion due to similar vial appearance between Fungizone and Ambisone, combined with passive nursing checks, created a risk of administering the wrong, more toxic medication.
View full coroner's concerns
(1) Fungizone and Ambisone have a similar drug vial appearance and can be confused. Fungizone is typically used as aerosol and Ambisone as an intravenous preparation: Fungizone has a smaller therapeutic window and is more toxic and may lead to a fatal hyperkalaemia as in this case (2) The nursing checks were described as passive rather than active
Report sections
Investigation and inquest
On 22/10/2017 commenced an investigation into the death of Sneh Lata Chaudhry aged 56 years The investigation concluded at the end of the inquest on 04/06/2018. The conclusion of the inquest was Sneh Lata Chaudhry died from immediate complications following administration of an incorrect formulation of amphotericin. The Medical Cause of Death was 1a Hyperkalaemia following amphotericin administration 1b multiorgan failure following high risk coronary surgery Ic triple vessel ischaemic coronary disease off pump coronary artery bypass grafting 4/10/2017 II Diabetes mellitus, morbid obesity and asthma
Circumstances of the death
Ms Sneh Latta Chaudhry had high risk coronary bypass grafting on the 4/10/2017 at Harefield Hospital with a prolonged stay in ITU. She developed a systemic candida infection. She required treatment with amphotericin: The wrong preparation of intravenous amphotericin was given (Fungizone rather than Ambisone). An HCA obtained the wrong preparation from the ward drug stock: The administering nurse and the checking nurse did not notice that the wrong preparation was obtained and then administered. The drug vials have a similar appearance.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:
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Report details
- Reference
- 2018-0182
- Date of report
- 15 June 2018
- Coroner
- Sean Cummings
- Coroner area
- London (West)
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: 2 Sep 2018 (estimated).
Sent to
- NHS England