A man died from a fatal overdose in hospital after miscommunication between doctors was “aggravated” through mask use, according to a coroner.
Hospital patient John Skinner was admitted to Watford General hospital suffering from seizures in May 2020.
He was given phenytoin, an antiepileptic medication.
As a result of failure in verbal communication between the doctors, aggravated as both were masked, a dose of 15mg/kg was heard as 50mg/kg and an overdose was administered
But due to a communication blunder, Mr Skinner was given a fatal dose of the medication and died from acute heart failure and phenytoin toxicity.
The usual phenytoin to treat epilepsy, as set out on the NHS website, is between 200mg and 500mg a day for adults.
Mr Skinner was administered 3,500mg.
Assistant coroner for Hertfordshire, Graham Danbury, wrote a prevention of future deaths report to highlight his concern that a similar overdose could happen again.
He said in the report: “The junior doctor instructed to administer the drug sought advice from a more senior doctor as to the dose to be administered.
“As a result of failure in verbal communication between the doctors, aggravated as both were masked, a dose of 15mg/kg was heard as 50mg/kg and an overdose was administered.”
Mr Danbury’s report, which has been sent to NHS England, said: “In my opinion there is a risk that future deaths will occur unless action is taken.
“This is a readily foreseeable confusion which could apply in any hospital and could be avoided by use of clearer and less confusable means of communication and expression of number.”
A spokesperson for West Hertfordshire Hospitals NHS Trust said: “A comprehensive action plan is in place to ensure that lessons are learned from this incident.”
