Dublin grandmother had fatal seizure after receiving wrong prescription at pharmacy, inquest finds

A DUBLIN GRANDMOTHER suffered a fatal seizure after taking medication supplied by a local pharmacy that was intended for another customer with a similar name and address, an inquest has heard.

Margaret Corcoran (73), mother of two from Tymonville Park, Tallaght, Dublin, aged 24, died at University Hospital Tallaght on 20 October 2022, eleven days after suffering a seizure related to taking medication that he had not been prescribed.

Her sister, Marian Reilly, told a hearing at Dublin District Coroner’s Court that she had called her sisters home shortly after midday on October 9, 2022 because she had not answered her phone calls .

Reilly described finding her sister on the floor next to her bed in an unresponsive state foaming at the mouth.

She alerted the emergency services and then checked her sisters medication and found it was prescribed for someone named Margaret Clarke.

The inquest heard Margaret Corcoran suffered severe brain damage as a result of a seizure she suffered in an ambulance while being taken to TUH.

In response to the coroner’s questions, Reilly said he had not noticed any major changes in his sister when he had last seen her about four days earlier.

He confirmed that Meaghers Pharmacy in Castletymon Shopping Center in Tallaght arranged for his sisters medication in blister packs to make it easier for her to take several pills at the right time as a result of a recommendation from her GP.

Reilly said her sister, who suffered from anxiety and depression, had been laid low during the Covid-19 pandemic as she had been forced to quit a part-time job she loved.

However, he stressed that his sister was in good physical health before her death and had no history of seizures.

Reilly told the coroner, Clare Keane, that he had not found any drugs near his sister in her bedroom.

When a paramedic also found the medication prescribed for another woman, she recalled: I said it’s not Margaret Clarke, it’s Margaret Corcoran.

Garda Brendan Carmody told the inquest he had kept the medication intended for Ms Clarke which had been given to the deceased.

Garda Carmody said the blisters showed Margaret had taken all of the various medications for four full days, as well as some other pills for a further two days.

A Meaghers Pharmacy Group representative, Elaine Lillis, offered the company’s deepest condolences to the Margarets family.

Lillis, the group’s superintendent pharmacist, said the wrong medication had been given to the deceased as a result of unfortunate and regrettable human error.

He said the pharmacy only realized Margaret had been given the wrong medicine after she was contacted by a TUH nurse following her admission to hospital.

Lillis, who was joined at the inquest by Meaghers Pharmacy Groups founder and owner Oonagh OHagan, said staff at the pharmacy were very shocked and upset by what happened.

The pharmacist said she immediately tried to establish how the error occurred and was also able to confirm that the other patient had not received the medication intended for Margaret.

Lillis confirmed that the pharmacist at its Castletymon outlet had correctly prepared and placed in a blister on 3 October 2022, as well as being correctly labelled.

He said the pharmacist had placed the medication in the correct slot in the pharmacy where it was stored before being picked up by a courier to deliver to Margarets home.

The inquest heard that a pharmacy technician had called Margaret at around 11.30am to check that she would be home to collect her weekly medication.

However, Lillis said the technician later took the medication from the hole above where Margarets’ prescription was kept.

Although CCTV footage showed the medication had been checked, Mr Lillis said the technician had not realized it was for a different customer but had later labeled a bag containing it with the name of Margarets.

Lillis said the technician was not interrupted at any point in the process and that what happened was unfortunately the result of human error in selecting medication from the wrong hole.

He told Dr Keane that there was also some similarity between the addresses of the two patients, as they both contained the word Tymon.

Lillis noted that the pharmacy dispensed about 70,000 items each year, adding: This is the first time a serious error like this has occurred.

As a result of what happened, the witness said that all pharmacists in the group were made aware of the error and the importance of complying with the prescribing processes.

He said counseling had also been provided to staff who were very upset.

Lillis said the pharmacy technician had been placed on administrative duties after taking time off before working under supervision for a period to return to dispensing duties.

The inquest heard that Meaghers had carried out several audits of his nine pharmacies and rearranged his storage practice in an alphanumeric manner to ensure that prescriptions for customers with similar names were not kept next to each other.

Labels placed on all prescription bags were also reviewed by two staff members, including one who must be a pharmacist, Lillis said.

He told the bereaved family’s barrister, Esther Earley BL, that Margaret had been given three different diabetes medicines meant for the other client which would have lowered the deceased’s blood sugar levels.

The inquest heard that a post-mortem examination had shown that Margaret died as a result of brain damage from lack of oxygen which occurred during the seizure.

Dr Keane said the findings could not determine the cause of the seizure, although it was possible it was the result of a drug overdose.

However, Earley said there was no evidence to suggest Margaret had taken a deliberate overdose and no medication was found at the scene, apart from medication intended for another pharmacy customer.

Returning a verdict of accidental death, Dr Keane said Margaret had died in a very tragic set of circumstances.

The coroner said it was very unlucky that the names and initials of the parties involved were similar, while their addresses also had similarities.

Dr Keane said it was clear Margaret’s health was stable at the time of her death, although she was suffering from a low mood.

He stressed that there was no error in the dispensing of the medication intended for Margaret, but that it had been incorrectly retrieved from the pharmacy when he arranged for it to be collected by a courier.

The coroner said some cognitive impairment with the deceased may also have affected her own ability to detect that she had been given the wrong prescription.

Dr Keane said she endorsed the changes Meaghers Pharmacy Group has already implemented to prevent the mistake from happening again.

The coroner said the case highlighted the importance of members of the public also checking their prescriptions to ensure they are getting the correct medicine.

After the inquest, Reilly said it was tragic that she had lost her only remaining sister needlessly.

It has been called a critical error, but it was a fatal error, Reilly said.

He added: My sister has grandchildren in Australia who are deprived of seeing her again. It should not have happened and the error should have been caught at an earlier stage.

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