Tragic death at Beaumont Hospital: medical error raises concerns

A Dublin woman has died after being given a fatal dosage of medication for blood pressure. Bernie Kinsella of Skerries, Dublin, passed away in Beaumont Hospital at 92 years old when she was administered eight times the recommended dosage of the drug lercanidipine in error.

This mistake resulted in severely low blood pressure, a known effect of the drug, which carries a high risk of serious injury if misused. Despite attempts to physically empty Ms Kinsella’s stomach, as well as a dosage of charcoal intended to undo the drug’s damage, the patient eventually succumbed to multi-organ failure as a result of the overdose.

Severe coronary artery disease was also identified as contributing towards her death. At the deceased’s inquest, Dublin District Coroner’s Court heard that, despite instructions from Ms Kinsella’s family, a junior doctor had listed the incorrect dosage on the patient’s chart. Medical staff at Beaumont Hospital had also misstated the dosage of another medication Ms Kinsella had been taking.

Ciara Reddy, one of Beaumont Hospital’s senior clinical pharmacists, admitted that these mistakes were unfortunately common at the hospital. However, she added that the majority are spotted and rectified quickly and rarely have the potential to cause serious harm.

Ms Reddy conceded that had she reviewed the chart, she would have noticed it as “exceptionally unusual” and cited understaffing as one of the hospital’s issues. Despite this testimony, it was revealed that another doctor had subsequently amended the chart to adjust the dosage timing and that this practitioner had also failed to identify the error.

Ms Kinsella’s family insisted that she was generally physically well and had remained active into her 90s. When she was admitted to the emergency department after suffering shortness of breath, her family expected her to return home after a couple of days. However, her health deteriorated severely after the error. One consultant, Imran Sulamain, admitted that her condition had progressed before the incident.

He also told the Court that there is no simple method to determine who should ultimately be responsible for administering patients’ medication. Beaumont Hospital does not have a set timeframe for medication review, but Prof Sulamain gave evidence that general practice was performed once daily.

Prof Sulamain explained to the inquest that the hospital hopes to move towards a digital system of prescribing which would reduce the risk of such accidents but that a lack of funding was stifling progress. Notwithstanding the many challenges, he hopes the system will be up and running by May 2025.

The nurse who administered the drug, Nimmy Matthews, questioned the 80mg prescription twice before ultimately following the chart. Ms Matthews immediately raised the alarm when she noticed a change in Ms Kinsella’s condition.

When explaining why she hadn’t held off on administering the lercanidipine, she stated that she was “just a nurse” and trusted that the responsible practitioners had recorded the medications accurately. She did, however, admit that she had previously administered the drug in regular doses of 10-20mg and was familiar with the drug generally.

The family emphasised their strong wish for change to be actioned by the hospital in the wake of Ms Kinsella’s death. They were aware that a review had been conducted following the incident, and they hoped this would lead to a systemic overhaul to reduce patient risk. “We don’t want another family to go through what Mammy had to endure.

It’s not an experience I’d wish on anybody,” said Ms Kinsella’s daughter. The coroner ultimately ruled the death a medical misadventure and strongly encouraged the hospital to follow the guidance shared by the external review group.

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