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Inquest finds gross failure in care and neglect led to death of Caroline Pearson-Smith

The inquest into the death of 52-year-old Caroline Pearson Smith has concluded that there were gross failures in her care and neglect, which led to her death.

19 December 2019

Caroline, of Basingstoke, died on 25 January 2016 after incorrectly receiving an overdose of Phenytoin at St Peter’s Hospital, Chertsey, Surrey.
 
Caroline went into the hospital after feeling very unwell while at her parents’ house. In the 12 months before this her health had deteriorated and she had been found unconscious leading to hospitalisation on two occasions.
 
Caroline had been diagnosed with multiple sclerosis in her late 20s. She managed her symptoms very well for many years and kept active but after gradual relapses for many years, she had become progressively limited in her daily activities.
 
She went to visit her parents in January 2016 and on the 25th January she again appeared unwell. Her speech was slurred and she became unresponsive so she was taken to St Peter’s Hospital. Caroline was seen by the clinicians and was prescribed phenytoin. Shortly after being given phenytoin she developed brachycardia and then suffered a fatal cardiac arrest.
 
Her parents waited in the A&E waiting room and were given very little information until being told that Caroline had died.
 
On review of her records after death, it was noted that 10gm of Phenytoin had been written on the drug chart. The hospital have indicated that this was a prescribing error in that only 1gm of Phenytoin should have been prescribed. The hospital contended that it would not have been possible to have given 10gm but they are unable to confirm the total amount of phenytoin which was given.
 
The day before the inquest was due to begin the family received an acknowledgment from Ashford & St. Peter's Hospital NHS Foundation Trust that Caroline’s care “fell below a reasonable standard of care with regard to the infusion of Phenytoin”. The Trust also accepted that this had led to her death.
 
Caroline’s family we represented at the inquest by clinical negligence solicitors Suzanne White and Firdous Ibrahim.
 
The family said following the conclusion:
 
“Caroline was a much loved and adored mother, daughter, sister and sister-in-law. Her sudden death was a terrible shock in such unexpected and tragic circumstances and was extremely distressing for the family. To find out that there were questions over how Caroline died and then to have to wait over three years for an inquest to find out how she came about her death, has put intolerable pressure on the family.
 
“The evidence given at the inquest illustrated that sadly Caroline was given very poor care when she was at her most vulnerable.  
 
“The verdict of by the Coroner was damning as the Coroner believed that there was a gross failure of care and neglect which caused Caroline’s death.
 
“We are still grieving as a family and now have to come to terms with the fact that Caroline should be still with us, and was taken away from us in such a tragic way.”
 
Suzanne White, head of the clinical negligence team at Leigh Day, added:
 
“Caroline’s death should not have happened and I am pleased that her family finally have some answers about the circumstances surrounding her death. The catastrophic error in over prescribing the amount of phenytoin Caroline needed caused her death and we are pleased that the Coroner acknowledged this in their conclusion. We hope that the Trust will now put robust measures in place to ensure such failures in patient safety do not happen again”

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