Finding into death of Elsa Harrington

45y · Female·Multisystem organ failure secondary to acute liver failure associated with paracetamol toxicity

Elsa Harrington, a 45-year-old woman, died from acute liver failure secondary to paracetamol toxicity in November 2002. She was admitted post-hysterectomy with bowel obstruction and underwent adhesion surgery. Following surgery, she received therapeutic doses of paracetamol and developed abnormal liver function tests on 8 November. However, clinicians failed to recognise these as paracetamol-related, instead attributing them to post-operative complications. Critical failures in communication and handover meant senior consultants were not notified of her deteriorating condition until Sunday, 48+ hours later. Her mental status changes (reflecting early hepatic encephalopathy) and reduced urine output were not recognised as indicators of acute liver failure. While paracetamol toxicity at therapeutic doses was poorly recognised in the medical literature at that time, earlier recognition of abnormal liver function tests, discontinuation of paracetamol, and prompt escalation to senior clinicians might have allowed earlier N-acetylcysteine treatment. The coroner identified systemic failures in communication, handover practices, and the lack of holistic clinical assessment as contributing factors.