Masks 'Aggravated' Miscommunication Between Doctors Leading To Patient's Overdose Death: Inquest Report

A patient in the U.K. has died after a doctor administered more than thrice the required dose of an anti-seizure drug due to a misheard communication.

Two years after the patient's accidental death to an overdose, a coroner has ruled that the miscommunication was "aggravated" as the doctors were wearing masks.

The patient, identified as John Skinner, was admitted to Watford General Hospital in May 2020 following complaints of seizure. Skinner reportedly had a background of cannabis usage and a subdural empyema (an abscess in the brain) that had left him with epilepsy.

The doctors decided to treat him with phenytoin, an antiepileptic medication, and a junior doctor was instructed to administer the drug, according to the coroner's report.

However, the junior doctor treating Skinner was unsure of the dosage and asked a senior doctor for advice. When the senior doctor replied 15kmg/kg, the instruction was misheard as 50mg/kg, resulting in the administration of a significant overdose.

Shortly after administering the medicine, Skinner died from acute heart failure and phenytoin toxicity and could not be revived, Wales Online reported.

"As a result of a failure in verbal communication between the doctors, aggravated as both were masked, a dose of 15 mg/kg was heard as 50 mg/kg and an overdose was administered," Graham Danbury, assistant coroner for Hertfordshire, England, said in a report.

"In my opinion, there is a risk that future deaths will occur unless action is taken," Danbury warned in the report. "This is a readily foreseeable confusion that could apply in any hospital and could be avoided by the use of clearer and less confusable means of communication and expression of the number," the report said.

Meanwhile, a spokesperson from the hospital which is under the National Health Service (NHS), the publicly funded healthcare system in England, said that they have ensured a comprehensive action plan is in place after the patient's tragic death.

"A comprehensive action plan is in place to ensure that lessons are learned from this incident," a spokesperson of the hospital said.

The NHS said it would be responding to the coroner's report on April 12, reported BBC.