Coroner rejects 'natural causes' conclusion for six stone mum given paracetamol overdoses
Laura Higginson's family had no idea she had been given multiple overdoses of paracetamol until three months after she died
A month-long inquest into the death of a 30-year-old woman at Whiston Hospital has come to an end. Mum-of-two Laura Higginson, from Widnes, was admitted to the hospital with suspected pneumonia on April 5 2017, where she was given "staggered overdoses" of paracetamol over a number of days before medics realised their mistake.
Simon Holder found the evidence provided during the inquest, which concluded at Bootle town hall today, December 23, was unable to determine that the overdoses had contributed to the mum's death from sepsis on April 19.
Handing down a narrative conclusion, he said: "On the evidence I have heard, from April 5 to April 7 Laura Higginson was administered excess staggered doses of paracetamol while a patient at Whiston Hospital. It has not been proven, on the balance of probabilities, that this contributed to her death days later."
The court previously heard that Laura, who was 5'1" and weighed 6st, had been given multiple doses of paracetamol which were too high for a woman of her size. On April 5, the day she attended hospital, she was given three 1g doses through an intravenous tube. This was repeated on April 6, and on April 7 she was given a final 500mg dose before medics realised their mistake and administered an antidote.
On April 7, Laura's condition rapidly worsened and she was rushed into ICU, where she was placed in an induced coma the following day. Her condition continued to deteriorate, and on April 18 her husband Anthony and children Steven, nine, and Evelyn, seven, were called to the hospital to say their goodbyes.
She died on April 19 2017, with her cause of death being multi-organ failure with sepsis, cirrhosis and pancreatitis.
Mr Holder said: "I have heard the (Mersey and West Lancashire Teaching Hospitals NHS) Trust's submission that a conclusion of natural causes would be appropriate. That is rejected.
"I also cannot accept the family's submission that neglect be recorded as a finding. I must explain... that neglect in coronial law is quite different. The definition of neglect in this context means a gross failure to provide adequate nourishment or liquid, or provide or procure basic medical attention or shelter or warmth for someone in a dependent position. I cannot find that the failures by the Trust amounted to a gross failure to provide the basics in medical care.
"The failures of care do have to be gross, and I don't find that the failures here - that mistake of administering the paracetamol - amounts to a gross failure."
He decided not to write a regulation 28 report for the prevention of future deaths, as the court heard a number of safeguarding measures had been put in place at the hospital since Laura's death. However he said he would write a letter to the CQC, the independent regulator of health and social care in England, as Laura's family had no idea the paracetamol overdose had occurred until three months after she had died.
He said: "I'm not satisfied that the duty of candour was discharged in this case. The doctor quite openly accepted that as the case. The Trust has committed to improving standards of patient care. But this duty of candour is in place to inform patients and their families, and it's accepted Dr Higginson should have been informed. The family should have been informed."