Inquest told Clare nursing home resident died after being given another person's medication

Coroner rules 'medication error' was a catalyst in events that led to John Mee's death

From left: Martin Kerrigan of Berwick Solicitors Galway, acting for the family, Bernadette Mee and Sr Gabriel Margaret Mee, sisters of deceased John Mee, and Doireann O'Mahony, barrister for the Mee Family, at Limerick Coroners Court Kilmallock, Co Limerick. Picture: Brendan Gleeson

A coroner has delivered a verdict of medical misadventure in the death of a man who was given an accidental overdose of medication, including another resident's, at a nursing home in Co Clare.

Limerick coroner John McNamara said the “medication error” by a nurse on duty at the Cahercalla Nursing Home, Ennis, was a “catalyst” in the events that led to John Mee’s death on June 30, 2021.

It was accepted by all parties Mr Mee, 71, from Miltown Malbay, Co Clare, was given another resident’s medication, including a high dose of anti-psychotic medication, in addition to Mr Mee’s own medication which he was receiving for a number of co-morbidity issues.

John Mee, of Miltown Malbay, Co Clare, died aged 71, in 2021. Picture: Brendan Gleeson

The erroneous overdose of prescribed drugs occurred at the nursing home around 9pm on June 24, 2021.

However, Mr Mee was not taken to hospital for 18 hours, despite being visibly drowsy.

Cahercalla NH staff nurse Collette Mannion, told the inquest, held at Kilmallock Courthouse, that she mistakenly gave Mr Mee some of his medication together with high doses of drugs that were prescribed to another resident.

'Unusually busy'

She said it was “unusually busy” at the nursing home on the night and that she and one healthcare assistant were looking after 23 residents on St Joseph’s ward.

Ms Mannion said that upon realising her mistake she checked Mr Mee and then contacted a “senior response person (SRP)”.

Ms Mannion also contacted the out-of-hours GP service Shannondoc and was advised to carry out regular observational checks on Mr Mee.

Asked if she had been under pressure on the night, Ms Mannion said some of the residents were “restless” and were “pressing” alarms in their rooms, “which needed to be answered promptly and we were trying to answer them as promptly as we could”.

She said Mr Mee “looked quite drowsy and that wasn't normal for John”, but she said he was still “responsive” and he appeared to be comfortable throughout the night.

It was accepted that possible side-effects of the overdosed anti-psychotic medication that was erroneously administered to Mr Mee, included drowsiness and dizziness.

Ms Mannion said Mr Mee’s “airway was not compromised”, and he was not in respiratory distress. 

She said had Mr Mee’s oxygen levels suddenly dropped to critically low levels “I would have rung for an ambulance”.

Extra checks now in place

She said “extra checks” were now in place at the nursing home in respect of the administration of mediation to residents, which she said included a “photograph” of the resident beside their room number and medication chart.

The new measures “certainly makes you more conscious of carrying out your duties thoroughly”, Ms Mannion said.

Caoimhe Daly BL, barrister representing Cahercally nursing home said Ms Mannion had “candidly accepted she had made an error”.

Maureen Hayward, a nurse who came on duty the following morning and took over caring for Mr Mee, said when she checked him he was “chesty” and “drowsy”.

Ms Hayward said she became “concerned” at Mr Mee’s oxygen saturation levels which were now reading 85%, and he was administered two litres of oxygen.

“I rang for an ambulance because I was concerned,” Ms Hayward said.

She said she could not exactly say when she contacted Mr Mee’s family, who complained they were not contacted for 15 hours after the medication error.

Ms Hayward said she had made “a mistake” when she included a drug that Mr Mee had not taken in a transfer letter sent with Mr Mee to UHL.

Respiratory distress

Dr Sean Fennessy, University Hospital Limerick, said when Mr Mee was placed in his care he was “in some respiratory distress” with a “chronic cough” and was diagnosed with “aspiration” (fluid in his lungs).

Dr Fennessy said Mr Mee’s condition eventually worsened and he died at the hospital on June 30.

Dr Fennessy agreed that Mr Mee was an “unwell patient” by the time he got to UHL.

Dr Gabor Laskai who conducted an autopsy on Mr Mee’s remains, said the cause of death was due to hemorrhage following extreme pancreatitis, pneumonia, and gastric stress erosions.

Coroner, John McNamara said he was satisfied that "this is an appropriate case where I should record a verdict of medical misadventure".

I want to stress I am not ascribing blame to anybody, I am not allowed to do so.

"Clearly John had something else going on that maybe no-one knew about, but nonetheless the overdose is a catalyst in the (overall) picture," Mr McNamara said.

The coroner said Cahercally NH had introduced a new “traffic light system, to try to prevent this eventuality happening again”.

He recommended Cahercally “adopt best practices” in respect of the administration of medicines for residents, which he was told it has done.