A Dublin grandmother suffered a fatal seizure after taking medicine supplied to her by a local pharmacy which was intended for another customer with a similar-sounding name and address, an inquest has heard.
Margaret Corcoran (73), a mother of two from Tymonville Park, Tallaght, Dublin 24, died at Tallaght University Hospital (TUH) on October 20th, 2022, 11 days after she suffered a seizure linked to taking medicines which had not been prescribed for her.
Ms Corcoran’s sister, Marian Reilly, told a sitting of Dublin District Coroner’s Court that she had called to her sister’s home shortly after midday on October 9th, 2022, as she had not answered phone calls from her.
Ms Reilly described finding her sister on the ground beside her bed in an unresponsive state with “frothing from her mouth.”
She alerted the emergency services and then checked her sister’s medication and found it was prescribed for a person called Margaret Clarke.
The inquest heard Ms Corcoran suffered severe brain damage as a result of a seizure she suffered in an ambulance while being brought to TUH.
In reply to questions from the coroner, Ms Reilly said she had not noticed any major change in her sister when she had last seen her about four days earlier.
She confirmed that Meaghers Pharmacy at the Castletymon shopping centre in Tallaght organised her sister’s medication in blister packs to facilitate her taking various tablets at the correct time as a result of a recommendation by her family doctor.
Ms Reilly said her sister, who suffered from anxiety and depression, had “went low on herself” during the Covid-19 pandemic as she had been forced to stop a part-time job which she loved.
However, she stressed that her sister was in good physical health before her death and had no history of seizures.
Ms Reilly told the coroner, Clare Keane, that she had not found any medication near her sister in her bedroom.
When a paramedic also found the medication prescribed for another woman, she recalled: “I said she isn’t Margaret Clarke, she’s Margaret Corcoran.”
Garda Brendan Carmody told the inquest that he had retained the medication intended for Ms Clarke which had been given to the deceased.
Garda Carmody said the blister packs showed that Ms Corcoran had taken all the various medications for four full days as well as some other tablets for two further days.
A representative of Meaghers Pharmacy Group, Elaine Lillis, offered the company’s “most heartfelt condolences” to Ms Corcoran’s family.
Ms Lillis, the group’s superintendent pharmacist, said the wrong medication had been given to the deceased as a result of “an unfortunate and regrettable dispensing human error.”
She said the pharmacy only became aware that the wrong medication had been given to Ms Corcoran after it had been contacted by a nurse at TUH following her admission to the hospital.
Ms Lillis, who was accompanied at the inquest by Meaghers Pharmacy Group’s founder and owner, Oonagh O’Hagan, said staff at the pharmacy were “very shocked and upset” over what happened.
The pharmacist said she immediately sought to establish how the mistake occurred and was also able to confirm that the other patient had not been given the medication intended for Ms Corcoran.
Ms Lillis confirmed that the prescribed medicine for Ms Corcoran had been correctly prepared and placed in a blister pack on October 3rd, 2022, by the pharmacist in its Castletymon outlet as well as being properly labelled.
She said the pharmacist had placed the medication in the correct “cubbyhole” in the pharmacy where it was stored before being collected by a courier to deliver to Ms Corcoran’s home.
The inquest heard a pharmacy technician had telephoned Ms Corcoran around 11.30am to check that she would be at home to collect delivery of her weekly medication.
However, Ms Lillis said the technician subsequently took the medication from the cubbyhole located above where Ms Corcoran’s prescription was stored.
Although CCTV footage showed the medication was checked, Ms Lillis said the technician had failed to notice that it was for a different customer but had then labelled a bag containing it with Ms Corcoran’s name.
Ms Lillis said the technician had not been interrupted at any stage during the process and what happened was unfortunately the result of human error by selecting medication from the wrong cubbyhole.
She told Dr Keane there was also some similarity between the addresses of the two patients as they both contained the word “Tymon”.
Ms Lillis noted the pharmacy dispensed around 70,000 items each year, adding: “It is the first time a serious error like this has occurred.”
As a result of what happened, the witness said all the group’s pharmacists were notified about the error and the importance of complying with prescribing processes.
She said counselling had also been provided to staff who had been “extremely upset.”
Ms Lillis said the pharmacy technician had been placed on administrative duties after taking some time off work before working under supervision for a period on returning to dispensing duties.
The inquest heard Meaghers had carried out multiple audits on its nine pharmacies and rearranged its storage practice on an alphanumeric basis to ensure prescriptions for customers with similar sounding names were not kept beside each other.
Ms Lillis said labels placed on all prescription bags were also now double-checked by two staff members, including one who must be a pharmacist.
She told counsel for the deceased’s family, Esther Earley BL, that Ms Corcoran had been given three different diabetic medications intended for the other customer which would have lowered the deceased’s blood sugar levels.
The inquest heard a postmortem had shown that Ms Corcoran died as a result of brain damage from a lack of oxygen which occurred during the seizure.
Dr Keane said the findings could not ascertain the cause of the seizure, although it was possible it was the result of a drug overdose.
However, Ms Earley said there was no evidence to suggest Ms Corcoran had taken a deliberate overdose and no drugs had been found at the scene apart from the medication intended for another customer of the pharmacy.
'Tragic circumstances'
Returning a verdict of death by misadventure, Dr Keane said Ms Corcoran had died in “a very tragic set of circumstances.”
The coroner said it had been very unlucky that the names and initials of the parties involved were similar, while their addresses also had similarities.
Dr Keane said it was clear that Ms Corcoran’s health was stable at the time of her death albeit she was suffering from a low mood.
She stressed that there was no error in the dispensing of the medicine intended for Ms Corcoran but that it had been incorrectly retrieved at the pharmacy when arranging for its collection by a courier.
The coroner said some cognitive impairment with the deceased may also have affected her own ability to spot that she had been given the wrong prescription.
Dr Keane said she endorsed the changes already implemented by Meaghers Pharmacy Group to prevent a recurrence of the error.
The coroner said the case highlighted the importance for members of the public to also check their prescriptions to ensure they received the correct medicine.
Following the inquest, Ms Reilly said it was tragic that she had lost her sole remaining sister unnecessarily.
“It’s been called a serious error but it was a fatal error,” said Ms Reilly.
She added: “My sister has grandchildren in Australia who are deprived of seeing her again. It shouldn’t have happened and the error should have been noticed at an earlier stage.”
