Inquest into the death of Audrey MacGREGOR

88y · Female·combined effects of an overdose of hydromorphone and complications of pneumonia (following treatment for chronic clostridium difficile colitis) against a background of heart disease and lung disease

An 88-year-old woman with chronic lung disease, heart disease, and recent pneumonia following faecal transplant for clostridium difficile colitis was prescribed 0.5 mg hydromorphone subcutaneously for respiratory distress on 24 October 2013. Two nurses unfamiliar with hydromorphone administered a 10-fold overdose (5 mg instead of 0.5 mg), mistaking the dose unit from milligrams to millilitres and confusing it with morphine. The patient rapidly lost consciousness and died hours later. Contributing factors included inadequate communication with family, lack of staff familiarity with the drug, absence of visual warnings distinguishing hydromorphone from morphine and high-potency versions, and delayed recognition of overdose signs by nursing staff. The coroner found the overdose contributed to death alongside pneumonia and underlying cardiopulmonary disease.