Doc gave mum killer dose
Dec 22 2009 by Jasbir Authi, Birmingham Mail
A MOTHER-of-four endured an agonising death after she was wrongly given ten times the normal concentration of a solution during a routine medical procedure, an inquest heard.
Rosemary McFarlane, aged 64, of Kingshurst Way, Kingshurst, was administered a lethal dose of phosphate buffer saline which caused her lungs to burn, by a consultant at Heartlands Hospital, who was unaware of the concentration’s strength, it was told.
The inquest into Mrs McFarlane’s death was told how she suffered from an underlying lethal condition called cryptogenic fibrosing alveolitis, which causes scar tissue to replace normal lung tissue.
The grandmother-of-five, who had never smoked, was admitted to Heartlands on August 4, 2008, after months of feeling unwell and experiencing difficulty walking and climbing stairs. On August 12, she underwent a routine bronchoscopy, where an instrument is passed through the mouth or nose into the lungs and fluid is squirted into a small part of the lung and then re-collected for examination.
Birmingham Coroner Aidan Cotter heard how Dr Adel Mansur, who had 16 years’ experience of conducting bronchoscopies, was handed a bottle of phosphate buffer saline from a new batch with no additional information, by staff nurse Karen Richardson. Dr Mansur told the inquest he was assumed it was the same strength as other bottles and that the ‘10X’ written on the bottle was part of the long labelling code.
When he injected Mrs McFarlane, the high dose caused water to move out of living cells leaving them damaged, dehydrated and causing adult respiratory distress syndrome, the inquest was told.
Nurse Richardson said she became greatly alarmed after the patient, who was expected to experience just mild discomfort after a bronchoscopy, started complaining of “severe burning” in her chest and other pains – something she had never seen in 14 years of practice.
The nurse and doctor then began frantically alerting other staff. Nurse Richardson told how the batch was immediately withdrawn as Mrs McFarlane’s condition continued to deteriorate.
With no known antidote, the patient was given steroids, oxygen and antibiotics, in the hope her condition would improve, as investigations were launched into how the solution had been supplied.
Mrs McFarlane’s family were informed the next day of what had happened by Dr Mansur who became very emotional and went down on his knees to apologise, the inquest heard. Mrs McFarlane died on August 22, from multiple organ failure which had been caused by the chemical accident, pneumonia, a bacterial infection and other complications. When asked by Mr Cotter why he didn’t check what 10Xs meant, Dr Mansur said: “Because to me it was a pure replacement to a normal phosphate buffer solution, it didn’t alert me.”
Earlier, pathologist Dr Adrian Warfield told how the wrong dose was so strong, it would have been enough to leave a fit, 30-year-old person, fighting for survival.
(Proceeding)
