Jacqueline Green
4 Apr 2025 · Coroner Emma Whitting · Bedfordshire and Luton
The coroner's concerns
1. unintentional paracetamol overdose in low-weight adult inpatients
“Despite the fact that the HSSIB made Safety Observations to mitigate the risks of unintentional paracetamol overdose in adult inpatients with low bodyweight in their National Report dated 24.02.2022 (https://www.hssib.org.uk/patient-safety-investigations/unintentional-overdse-of-paracetamol-in-adults-with-low-bodyweight/) none of these had been addressed/adopted at Bedford Hospital by the time of the Deceased's admission on 29 August 2023 which meant that, despite weighing only 33.6kg, the Deceased”
2. administration of excessive paracetamol dose after inaccurate weight estimation
“2. A lengthy PSII investigation (completed on 16 September 2024 and received by the Senior Coroner on 24 October 2024) delayed the hearing of the Inquest but also left unanswered questions. In particular, there was no explanation as to why the nursing staff, having estimated the Deceased's weight at 44 kg the day after the paracetamol was prescribed (which although quite incorrect was still below the threshold for a prescription of that level) still proceeded to administer the prescribed dose yet did”
3. lack of weight accuracy alerts in electronic prescribing system
“a) Although Bedford Hospitals NHS Trust are now using the Nervecentre electronic record system which, since 28th February 2024, has included the height and weight of patients and prevents a prescribing doctor from prescribing without a patient's weight having first been entered, staff are still able to enter a estimated weight and there do not appear to be any alerts on this system to advise of the need for weight accuracy in the prescription of oral paracetamol and consideration of the risk of liver”