Paula Doreen Hughes, 55, was admitted to the Woolwich hospital on January 6, 2022, having fractured her arm in a fall the following evening.
Over the next 48 hours in hospital she received a fatal overdose of paracetamol, according to a prevention of future deaths report.
This was a consequence of paracetamol being prescribed in addition to co-codamol, which already contains paracetamol, the document said.
Inner South London coroner Liliane Field concluded that Mrs Hughes’ cause of death was liver failure as a result of paracetamol overdose.
On December 19, the prevention of future deaths report produced by Dr Field was published warning that there is a risk of further casualties unless action is taken.
Dr Field said the two drugs were administered together on three or four occasions before it was corrected.
Two prescribing doctors, two nurses and a pharmacist failed to recognise the problem, according to the report.
Mrs Hughes’ condition began to deteriorate at around 12pm on January 8 but the coroner said staff did not recognise that she had been given a paracetamol overdose until the following morning.
By that point she had been admitted to intensive care.
Dr Field said the delay had meant that Mrs Hughes was not given potentially life-saving drug n-acetyle cysteine in time.
Lewisham and Greenwich NHS Trust was sent a copy of Dr Field’s report on October 14 last year.
The trust has outlined plans to implement several new systems to prevent similar deaths from occurring – a full copy of the trust’s response can be found here.
The coroner said the trust’s response was “swift and commendable” with a hard stop introduced to the electronic prescribing system they had been using.
But Dr Field warned that any safety nets should not be diluted or lost as the trust changed its electronic record and prescribing system.
The trust has been contacted for comment.
