Prevention of Future Deaths report - John Skinner (11 February 2022)

Summary

On the 15 May 2020, John Skinner was admitted to Watford Hospltal suffering from a tonic clonlc seizure. He had a background of cannabis usage and a subdural empyema in 2020 that had left him with epilepsy. On arrival at hospital he again had another tonic clonlc seizure and focal seizures.

The Junior doctor Instructed to administer the drug sought advice from a more senior doctor as to the dose to be administered. As a result of a failure In verbal communication between the doctors, aggravated as both were masked, a dose of 15 mg/kg was heard as 50 mg/kg and an overdose was administered.

He was given 3600 mg of phenytoln. He arrested within 16 minutes and died and could not be revived. 

Content

In this report, the Coroner states his concerns as follows:

• The Junior doctor Instructed to administer phenytoln did not know the required dosage and asked his more senior colleague for advice. The senior doctor's reply 15kmg/kg was heard by the Junior doctor as 50mg/kg resulting in administration of a significant overdose.
• This Is a readily foreseeable confusion which could apply in any hospital and could be avoided by use of clearer and less confusable means of communication and expression of number.