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Inquiry Under the Fatal Accidents and Inquiries (Scotland) Act 1976 into the Sudden Death of Danielle Welsh, Sheriff Andrew M Cubie, Glasgow Sheriff Court, 2nd February 2011


In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that Danielle Welsh died on 24th June 2008 at 10.25am at the Royal Infirmary of Edinburgh. In terms of section 6(1)(b), the cause of death was Liver failure due to paracetamol toxicity caused by iatrogenic paracetamol overdose. Formal determinations were made under section 6(1)(c), (d) and (e).
Danielle was 19 at the time of death and suffered from an unidentified condition causing spondyloepiphyseal dysplasia, short stature, mild but longstanding learning difficulties, problems with hearing and chronic pain. At June 2008 she weighed 35kg.

On 15th June 2008 Danielle became unwell and was taken to the Southern General Hospital. She was prescribed intravenous paracetamol at a dose of 1g four times daily. This was prescribed by a junior doctor who did not check Danielle's weight. She should have received 525mg per dosage. Danielle received 20 such doses over five days during which her condition was monitored by 21 clinicians. None of these individuals knew that paracetamol was prescribed differently if administered intravenously and if the patient weighed less than 50kg.

With the exception of the paracetamol overdose, Danielle received attentive, focused and appropriate care. However, there was a gap in the knowledge of all those who prescribed, administered, reviewed and considered the intravenous paracetamol prescription.

Under s.6(1)(c) the sheriff found that Danielle's death could have been avoided if: the prescribing doctor had checked the British National Formulary (BNF) before prescribing intravenous paracetamol; the nursing staff administering the drug had checked that the dosage was appropriate for Danielle's weight; and the pharmacist had checked the BNF when reviewing the prescription. Under s.6(1)(d) the sheriff found that there were no defects in the system of working which contributed to Danielle's death. Under s.6(1)(e) the sheriff found that there was a culture of assumed familiarity with intravenous paracetamol which was misplaced.

A number of recommendations about procedures for prescribing intravenous paracetamol were made by parties. These were rejected by the sheriff on the basis that they were outwith the scope of the hearing.