Pensioner’s death not linked to double dose of wrong drug at Royal Free Hospital

Electrical engineer Gloria Floretta Roberts, 68, was admitted to the hospital in November last year and there was no sign that anything was amiss on the day she died, an inquest at St Pancras Coroner’s Court heard last Wednesday (June 13).

But two hours before her death she rapidly deteriorated and was given drugs.

Her daughter Dianne Roberts White, who gave evidence, said: “When my father was there, she was okay.”

He saw staff administer drugs to his wife and shortly afterwards she died, the court heard.

Mrs Roberts White said the family wanted to know why the drugs had been given and if this was correct procedure.

Divisional nurse director Julie Meddings said the drugs had been administered correctly but admitted mistakes had been made in the days before Mrs Roberts’ death.

Staff had used an old drug chart to treat the electrical engineer, which dated from May when she was admitted to intensive care.

The drug chart had not been filed properly causing it to fall out of Mrs Roberts’ file and a staff member wrongly re-filed it as current.

This resulted in staff using the old drug chart along with the current chart from November 16 and Mrs Roberts was mistakenly given two doses of Ciprofloxacin, an antibiotic that had been used to treat her in May.

The drug can worsen muscle weakness and cause breathing difficulty in people with myasthenia, a condition where muscles become easily tired and weak which Mrs Roberts suffered from.

The mistake was only spotted two days later shortly before she died.

Summing up, deputy coroner Dr Shirley Radcliffe, said: “There was no evidence that the Ciprofloxacin had given any serious side effects.”

A post-mortem examination found Mrs Roberts, who lived in Wakefield Road, New Southgate, died from pneumonia with chronic kidney disease a contributing factor.

The coroner was told the hospital in Pond Street, Hampstead, has since reviewed procedures and made changes.