Coroner calls on Bedford Hospital to make changes after pensioner weighing FIVE STONE dies from paracetamol-induced liver failure

Emma Whitting, senior coroner for Bedfordshire and Luton, has slapped a Prevention of Future Deaths report on Bedford Hospital, following the case.

And the hospital says it has now introduced new protocols to ensure underweight patients only receive reduced paracetamol.

Jacqueline Green, aged 72, was admitted to hospital, having been found on her bedroom floor in 2023.

She reported to her carer she’d been there since falling in her dining room and crawling to her bedroom TWO DAYS BEFORE.

The pensioner was described by the attending paramedics as being very weak, very slim and frail – however, her weight wasn’t taken before nursing staff asked a night junior doctor to prescribe her with paracetamol.

In Ms Witting’s report, she said: "Although nursing staff estimated her weight at 44kg the following day, and her actual weight was confirmed to be 33.6kg [5 stone and 4lbs] sometime on August 31, 2023, she continued to receive the prescribed dose of paracetamol until the evening of August 31, 2023, when the last dose was withheld by nursing staff. The reason for the withholding of the last dose of paracetamol remained unclear."

Ms Green began vomiting and was given a further reduced dose of paracetamol – however, tests showed a "significant derangement in her liver function".

It was only then that staff stopped giving her paracetamol, and she was treated for paracetamol-induced liver injury.

But her condition deteriorated and she was placed on end-of-life care before dying on September 3, 2023.

You can read the full report here

Ms Witting said: "During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken."

She added that despite the fact Health Services Safety Investigations Body (HSSIB) had outlined the risks of unintentional paracetamol overdose in underweight adult inpatients, none of these had been addressed/adopted at Bedford Hospital.

This meant that despite weighing only 33.6kg, the pensioner was prescribed a daily dose of 1,000mg x 4 which was only suitable for a patient weighing in excess of 50kg.

As far as Ms Witting is concerned, there were "unanswered questions", and she said further exploration with the relevant staff "might well highlight additional safety concerns".

She told Bedford Hospitals NHS Foundation Trust: "In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action."

David Carter, chief executive of Bedfordshire Hospitals NHS Foundation Trust which runs the hospital, said: "First and foremost I would like to express my sincere condolences to Jacqueline's family and loved ones.

"Following the safety issue concerns raised by the coroner, we have undertaken a comprehensive investigation into the circumstances surrounding Jacqueline's death. As a result, we now have new nursing protocols and equipment in place concerning the care provided to patients who require IV paracetamol but at a reduced amount due to being underweight.

"We always aim to provide the best possible care to our patients and I would like to reassure Jacqueline's family that we have taken important safety lessons from her death which should prevent a similar event happening in the future."

And, in a letter to Ms Witting last month, the chief executive said: “Within her statement, the nurse has acknowledged that further action should have been taken on August 31 to alert the medical staff of the need to amend the prescription. A handover should have also occurred when she ended her shift to ensure that the nurse who took over the care of Jacqueline was aware of the fact that Jacqueline was under 50kg and would need a reduced dose of IV paracetamol.”

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