The death of an individual who was subjected to an unintended overdose at a nursing home situated in Ennis, Co Clare, has been categorised as a medical mishap following an official inquest. The man, identified as John Mee, passed away on June 30th, 2021, as a result of a “medication blunder” by a duty nurse at Cahercalla Nursing Home – a mistake that Limerick Coroner John McNamara referred to as a “trigger” behind Mr. Mee’s ultimate demise.
The inquest held at Kilmallock Courthouse acknowledged globally that Mee, a 71-year-old from Miltown Malbay, was erroneously administered another resident’s strong antipsychotic drug on top of his prescribed medication. The unfortunate mishap unfolded at approximately 9pm on June 24th, 2021. Remarkably though, it wasn’t until a whopping 18 hours later, a period throughout which Mr. Mee displayed noticeable lethargy, that he was transferred to a hospital.
Regarding the incident, staff nurse at Cahercalla, Collette Mannion, confessed to accidentally dispensing the incorrect medication to Mr. Mee during an unusually hectic period at the nursing home. On this particular night, Mannion and a single healthcare assistant found themselves responsible for 23 residents in St Joseph’s ward. Upon realising her grave mistake, Mannion undertook checks on Mr. Mee and reached out for assistance from a “higher-ranking respondent”. She also notified an out-of-hours medical practitioner’s service and was advised to continue monitoring Mr. Mee regularly.
Conveying the stressful atmosphere of that fateful night, Ms Mannion recollected how some residents were “antsy” and often triggered their room alarms that the staff attempted to address as quickly as possible. She found Mr. Mee to be “noticeably lethargic”, a state noncharacteristic for him, but he exhibited signs of comfort and responsiveness. Given that the wrongly administered antipsychotic drug could induce symptoms of drowsiness and dizziness, the observations made by Ms. Mannion were pertinent. However, she clarified that she would’ve summoned an ambulance if Mr. Mee’s oxygen levels had suddenly dropped to critically low levels.
Ms Mannion announced the implementation of additional checks concerning the dispensing of medication at the nursing home. This includes a photograph of the resident alongside their room information and medicinal chart. Caoimhe Daly BL, representative for the nursing home, stated that Ms Mannion had openly acknowledged her error.
In a handover the next day, Mr Mee’s care was passed on to nurse Maureen Hayward. She recalled Mr Mee as being lethargic and having a congested chest during her initial check. Upon being alarmed by Mr Mee’s low oxygen saturation levels, she ensured the administration of two litres of oxygen before alerting the ambulance. Although the timing of the communication with Mr Mee’s family was uncertain, they claimed to not have been informed till 15 hours post the medication mishap.
Hayward confessed that an error was made in the transfer letter sent to University Hospital Limerick (UHL) along with Mr Mee, citing a drug he had not taken.
At UHL, Dr Sean Fennessy reported that on arrival, Mee presented signs of respiratory distress, a persistent cough, and fluid-filled lungs. His condition took a turn for the worst, leading to his death on June 30th, with him being unwell upon admission.
Mr Mee’s post-mortem, conducted by Dr Gabor Laskai, determined the cause of death as a progression of severe pancreatitis, pneumonia and gastric stress erosions leading to haemorrhage.
The coroner deemed the overdose unintentional but considered it as a potential contributing factor to Mr Mee’s death, concluding a verdict of medical misadventure. Wanting to clarify, he stated “Although it seems there were other undiagnosed issues with John, it’s possible that the overdose triggered an [overall] effect. However, I am not accusing anyone, it is not within my purview to do so.”
He urged Cahercally Nursing Home to always maintain the best practices regarding medicinal administration for its residents, which he was informed was already in place.
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