A 69-year old woman, who was inadvertently given a lethal dose of potassium chloride died after an operation at University College Hospital, Galway, an inquest heard yesterday. Mrs Veronica Connolly, of Whitestrand Road, Galway, entered hospital on October 14th last year for an operation to correct a rolling hiatus hernia.
Consulting surgeon Mr Denis Quill, who performed the operation, said everything went well. Immediately after the 40-minute procedure, senior house doctor Dr Martin Grennell asked Mr Quill if he would give Mrs Connolly the usual antibiotic which Mr Quill gave his post-operative patients. Mr Quill said he agreed to this.
Following the administration of the antibiotic, Mrs Connolly was taken to the recovery room where she suffered a cardiac arrest. Senior anaesthetist Dr Noel Flynn was called and staff spent 30 minutes trying to resuscitate the woman.
Dr Malcolm Little, pathologist, told the inquest he was in a "quandary" to know what Mrs Connolly had died from. He and Dr Flynn collaborated in a full investigation and Dr Flynn told him he was concerned that Mrs Connolly had been given an antibiotic mixed with strong potassium chloride. This would have caused the cardiac arrest.
The inquest heard that Dr Grennell (29) had inadvertently diluted two ampoules of the powdered antibiotic, Zinacef, with two phials of potassium chloride instead of water. Both liquids were on the anaesthetic trolley in the operation theatre. They were both clear liquids and the phials had very similar labelling. Dr Grennell mistakenly used the potassium to make the solution and then administered the dose intravenously.
Giving evidence, Mr Quill said the hospital had now introduced a new protocol for handling dangerous drugs. He said the incident was due to human error but there was an obligation on the hospital to minimise this sort of thing happening again.
The inquest heard that the potassium phial had a small red label on it, but from the back it looked similar to the water phial.
Under cross-examination from Mr Owen Garavan BL, for the Connolly family, Mr Quill said he was not aware if staff were checked for colour blindness, even though 10 per cent to 12 per cent of the male population suffered from this condition.
Dr Flynn, head of anaesthesia at the hospital, said that following the incident, two empty potassium chloride phials and two empty Zinacef ampoules were found on the anaesthetic trolley. He said the potassium chloride phials were normally stored in the second drawer of the trolley where all "emergency" drugs were stored. He could not explain where Dr Grennell had found the phials. The phials containing water, which were normally used for diluting antibiotics, were to be found on the top of the trolley.
Dr Little, pathologist, said Mrs Connolly died from an accidental dose of potassium chloride due to accidental injection causing cardiac arrest. The inquest continues today.