Inquest Into The Death Of Jessica Hilary Bovill

43y · Female·Severe diffuse hypoxic brain injury caused by administration of supratherapeutic level of sodium bicarbonate in treatment of amitriptyline overdose

A 43-year-old woman died from severe diffuse hypoxic brain injury caused by excessive sodium bicarbonate administration during treatment of amitriptyline overdose. The treating ED consultant prescribed sodium bicarbonate at 2 mmol/kg repeated every 3-5 minutes without consulting official Therapeutic Guidelines or toxicology services. Over 1180-1600 mmol was administered (1.8-3 times the maximum recommended 660 mmol dose), causing severe hypernatremia (peak 169 mmol/L), metabolic alkalosis, and hypokalaemia. Brain swelling and death resulted. The consultant failed to adequately monitor blood gas results showing critical electrolyte derangements, did not consult available Toxicology Hotline until after excessive dosing, and lacked awareness of maximum dosing limitations in guidelines. Amitriptyline overdoses rarely cause death with appropriate treatment; statistical evidence suggests this patient would likely have survived with correct sodium bicarbonate dosing.