She had been taken to hospital after fracturing her upper arm bone
Paula Doreen Hughes was given an “overdose” of co-codamol and paracetamol at Queen Elizabeth Hospital(Image: Michael Malorny)
A 55-year-old woman died after being prescribed a deadly cocktail of drugs at a south east London hospital. Paula Doreen Hughes was given an “overdose” of co-codamol and paracetamol at Queen Elizabeth Hospital, a coroner has ruled.
Mrs Hughes had been taken to hospital after fracturing her upper arm bone on January 6, 2022. Doctors accidentally prescribed her two paracetamol-containing drugs, paracetamol and co-codamol, which led to failure of her liver and a drug overdose.
She was prescribed the two drugs at the same time on three or four occasions between January 6 and 8. The duplicate prescription wasn’t deleted from the hospital system until around 2.30pm on January 8.
Mrs Hughes’ condition began to deteriorate on at around 12pm that day, but hospital staff still didn’t recognise that she had been given an overdose of paracetamol until the following morning. By this point, she had already been admitted to intensive care with fulminating acute liver failure, which is often caused by drug overdoses.
This delay meant that Mrs Hughes was not given a potentially life-saving drug, called n-acetyl cysteine, in time. She later died at Queen Elizabeth Hospital of liver failure and paracetamol overdose. Ischaemic heart disease, urinary tract infection, diabetes mellitus and excess alcohol consumption were also recorded as causes of death.
Two prescribing doctors, two nurses and a pharmacist failed to recognise that Mrs Hughes was being given a duplicate prescription, found Coroner Liliane Field for London Inner South at an inquest on October 14, 2025.
Hospital staff also failed to ask Mrs Hughes if she had taken any other medication before she came into hospital. This meant that doctors not know that she has already taken a dose of over-the-counter paracetamol.
Mrs Hughes would also have been given the medical treatment she needed quicker if medical staff had recognised her “state of confusion”, the inquest found. The coroner called upon Lewisham and Greenwich NHS Trust, NHS England, The Royal Pharmaceutical Society, Cerner, The Medicines and Healthcare products Regulatory Agency and The Royal College of Physicians to respond to the report within 56 days.
The trust has since outlined plans to implement several new systems to prevent a similar death from occurring. These include a hard stop to check for duplicate prescriptions and improved training on how to recognise states of confusion.
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