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Isle of Man Courier
October 13, 2013 08:20
An inquest has heard for the second time in eight days that a fundamental error in flawed results at Noble’s Hospital, indicated that an elderly woman, who died from natural causes, had died from fatally high levels of antidepressants in her system.
The inquest into the death of Norma Knowles, aged 76, of King’s Reach Nursing home, Ramsey, reconvened at Douglas Courthouse on Wednesday.
At the inquest Mrs Knowles’s brother-in-law Peter Matthews said he hoped no other family would be put through the trauma that Mrs Knowles’s family has been put through.
Mrs Knowles, who suffered from chronic illnesses, had been taken ill at the nursing home on December 31, 2012.
A doctor had been called out to the home and wanted Mrs Knowles to go into hospital, because he thought she had pneumonia, but she refused to go into hospital.
Mrs Knowles’s health deteriorated and she was later rushed to the A and E department, where she later died.
Toxicology tests carried out at Noble’s Hospital showed that Mrs Knowles had a high level of the prescribed drug amitriptyline in her system and the cause of death was recorded as an overdose.
The tests, which were carried out twice, showed high levels and doubt was cast on the accuracy of the results.
Further tests were then carried out in Sheffield, which showed she ‘had a therapeutic level of the drug in her system’.
The same problem occurred after the death of Peel man Andrew Sharpe, whose inquest was held last week.
James Cooper, a senior biomedical scientist, told the inquest that the test carried out should have been to determine the presence of such a drug, not the quantity of it.
Mr Matthews asked Mr Cooper if all his colleagues had been using the equipment wrongly for the last four years.
Mr Cooper replied: ‘Regrettably so. Unfortunately it was a human error with the installation of the system.’
The coroner Jayne Hughes apologised to the family for the delay in finding out the results at a distressing time for the family.
Mrs Hughes said: ‘It was clearly a fundamental error, I am sure it won’t arise in the future.’
The coroner said there had been no suggestion that Mrs Knowles had been neglected or mistreated at the nursing home.