Probe into OAP Kusumben Kapadia given overdose of morphine

Published: 12 February 2010
by JOSIE HINTON

AN investigation has been launched after a 69-year-old woman was injected with 30 times too much morphine hours before her death.

Senior bosses of Islington’s Palliative Care Team – the NHS body responsible for treating terminally ill patients in their own homes – say they are investigating whether the tragedy could have been prevented.

An inquest at St Pancras Coroner’s Court heard on Tuesday how Kusumben Kapadia was mistakenly administered with a fatal overdose of Oxycodon – a synthetic form of morphine – while at her home in Giesbach Road, Archway.

She was suffering from terminal cancer and had undergone two rounds of chemotherapy at St Bartholomew’s Hospital but was discharged on October 5 last year to die at home, after doctors told her she had less than a week to live.

She had been taking her medicine orally, but nurses responsible for her care at home switched it to a syringe on October 9 when she could no longer swallow.

She was supposed to receive 2mm per hour – but an error meant she was given 60mm, and she died that evening. The alarm was raised when an out-of-hours GP noticed the syringe containing morphine was empty.

Coroner Andrew Reid ruled that the overdose was not the cause of Ms Kapadia’s death, but Dr Chi Chi Cheung, who heads up Islington’s palliative care team, told the court investigations were being carried out into how the error could have been allowed to happen.

She said: “The syringe driver is not locked. It could either have been set up incorrectly or it could have been changed afterwards. Senior people within the team have been in discussion with the district nurses about whether this could have been prevented.”

The court heard how the nurse who set up the syringe was “highly credible” and the device was found to be working properly.

Dr Reid said the circumstances surrounding the overdose remained “unexplained” but insisted it did not ultimately cause her death.

Recording a verdict of natural causes, he said: “The evidence has been unable to show how, when or why the rate was changed. 

“However, the level of Oxycodon was still relatively low and would not have caused an overdose in this lady. The overwhelming evidence is that she died from her cancer.”

He added: “I understand that fail-safe systems for syringe drivers are something that the healthcare services involved will consider in an attempt to stop this happening again.”