Danielle Welsh: Died of liver failure in June 2008. Pic: © STV
Three doctors and a pharmacist failed to realise that a patient they were treating was being given too much paracetamol, a fatal accident inquiry has heard.
Nineteen-year-old Danielle Welsh was given almost double the recommended dose of the painkiller 20 times between June 18 and 22, 2008.
The teenager, who had a rare syndrome which meant she weighed just five and a half stones and was only four feet tall, was given an amount designed for an adult weighing just under eight stones.
Danielle had been admitted to Glasgow's Southern General Hospital with a suspected infection. She died at the Royal Infirmary in Edinburgh on June 24, 2008, from liver failure.
The inquiry at Glasgow Sheriff Court heard that while Danielle was in the hospital, she was transferred to the neurological ward for tests.
Consultant neurologist Dr James Overell told the inquiry that he saw Danielle on June 19 but was unaware that she was receiving the drug intravenously and could not be sure if he even knew that she was being given paracetamol.
Dr Overell added: "I would have been told the drugs she was on and I would have advised on them but I doubt that anyone mentioned paracetamol.
"They wouldn't tell me if she was on paracetamol or the dosage of it. We would tend to concentrate on the drugs related to what we were doing in the neurology department.
"We would not tend to concentrate on drugs that are seemingly benign.
Dangers
"Obviously paracetamol does have dangers but it's very unusual to see problems with paracetamol which has been prescribed."
Dr Overell told the inquiry that Danielle, of Glasgow, was seen by two other doctors and a pharmacist while she was on the ward.
Procurator fiscal depute Gail Adair asked the medic who would be responsible for reviewing Danielle’s drug intake.
He replied: "Everybody is responsible. The standard procedure is that the pharmacist would review the drug cardex and would tell the junior doctor if there had been a mistake."
Mrs Adair asked: "Danielle was given a dose that was to much for her body, is it fair to say that that error was not picked up while she was in the neurological ward?"
Dr Overell replied: "Yes."
Mrs Adair asked if he could say who had the biggest responsibility when it came to the drugs being given to a patient.
He replied: "I guess it's not really my place, but I would say that the responsibility primarily lies with the person who prescribes.
"But clearly we all have a responsibility to check and clearly these systems for checking failed on this occasion."
The inquiry earlier heard that junior doctor Shamita Das prescribed the drug for Danielle without ever seeing her.
Dr Das said that this was the first time she had ever been asked to prescribe the drug and she gave an adult dose not realising how light Danielle was.
The inquiry also heard that a nurse did not read an instruction leaflet on the dosage of IV paracetamol before giving Danielle too much.
Charge nurse Melanie Gale said she "made an assumption" that the liquid form of the drug had the same dosage as the tablets.
Miss Gale also admitted that she treated Danielle as a normal adult even though she was only four feet tall and weighed five and a half stone.
The inquiry, before Sheriff Andrew Cubie, continues.
