A month-long inquest into the tragic death of a young parent has finally concluded, with a coroner stating that mistakes made were not gross failures. Laura Higginson from Widnes, Cheshire, was admitted to Whiston Hospital in April 5 2017, after it was thought she was suffering from pneumonia.
The court previously heard that medics gave Laura ‘staggered overdoses’ of paracetamol over a two-day period before realising their error. She was then immediately given an antidote to counteract these effects, with the Hospital Trust claiming that the drug did not cause her death.
While Coroner Simon Holder rejected its alternative conclusion of ‘natural causes’, he was unable to determine whether the overdoses had contributed to the mum’s death from sepsis on April 19. Speaking at the inquest at Bootle Town Hall on Monday, he explained: “On the evidence I have heard, from April 5 to April 7 Laura Higginson was administered excess staggered doses of paracetamol while a patient at Whiston Hospital.
“It has not been proven, on the balance of probabilities, that this contributed to her death days later.” During the inquest, it was heard that Laura, who was 5ft 1ins tall and weighed six stone, had been given multiple doses of paracetamol which were too high for a woman of her size.
On the first day she attended hospital (April 5), she was given three doses through an IV line, according to Manchester Evening News. This was repeated on April 6 and on April 7, where she was given a final dose before hospital staff realised their error and administered an antidote.
That same day, Laura’s condition dramatically deteriorated and was rushed to intensive care. Although she was put in an induced coma the following day, her health continued to worsen and on April 18 her family were called to the hospital to say their goodbyes.
Laura died on April 19 2017, with her cause of death noted as multi-organ failure with sepsis, cirrhosis and pancreatitis, reports The Echo. Mr Holder said: “I have heard the (Mersey and West Lancashire Teaching Hospitals NHS) Trust’s submission that a conclusion of natural causes would be appropriate. That is rejected.
“I also cannot accept the family’s submission that neglect be recorded as a finding. I must explain… that neglect in coronial law is quite different. The definition of neglect in this context means a gross failure to provide adequate nourishment or liquid, or provide or procure basic medical attention or shelter or warmth for someone in a dependent position. I cannot find that the failures by the Trust amounted to a gross failure to provide the basics in medical care.
“The failures of care do have to be gross, and I don’t find that the failures here – that mistake of administering the paracetamol – amounts to a gross failure.” Mr Holder did not write a regulation 28 report for the prevention of future deaths, as the court heard that various safeguarding measures had been enforced at the hospital since Laura’s death.
However, he did state that a letter would be sent to the Care Quality Commission, the independent regulator of social care in England, as Laura’s family had no idea the paracetamol overdose had occurred until three months after she had died.
“I’m not satisfied that the duty of candour was discharged in this case,” Mr Holder added. “The doctor quite openly accepted that as the case. The Trust has committed to improving standards of patient care. But this duty of candour is in place to inform patients and their families, and it’s accepted Dr Higginson should have been informed. The family should have been informed.”