A Donegal nursing home has put new patient care structures in place after a 97-year-old resident was given almost ten times the recommended dose of morphine.
Details of the medical mishap were revealed at an inquest into the death of pensioner Marie Glackin who was from Main Street in Dungloe.
Mrs Glackin, who was a resident of the Larissa Lodge Nursing Home in Letterkenny, passed away on May 24th, 2020.
Some weeks earlier on April 23rd, she had contracted Covid and was put into isolation in the nursing home but was asymptomatic.
Mrs Glackin was taken to Letterkenny University Hospital and stayed there from May 14th until 18th after developing a respiratory infection.
However, she soon required oxygen as her oxygen saturation levels were at 88 per cent when a normal person's breathing levels are at above 93 per cent.
Her general condition deteriorated, and her family were informed that she would require palliative care, but the family agreed that they would like her to remain in Larissa Lodge as she was receiving good care.
A report on Mrs Glackin's care and her final days was given to the inquest by Abhilash Pattathil who was in charge of the facility.
He read out a report detailing how Mrs Glackin was prescribed 1-2 of OxyNorm (a morphine-based drug) every four to six hours and that a nurse had been assigned to sit with Mrs Glackin.
At this stage Mrs Glackin was receiving full end-of-life care from the nursing home.
On May 24th, Mrs Glackin sadly passed away, and her death was recorded at 3.37pm, seven hours and 22 minutes after she was given 10 milligrams of OxyNorm.
It was noted that the previous day, at 1.20pm Mrs Glackin had also been given another 10 milligrams of the same drug, OxyNorm.
The nursing home realised their mistake and immediately contacted the authorities.
Giving evidence in the case pathologist Dr Gerry O'Dowd said he took a blood sample from Mrs Glackin's remains.
Upon examination Dr O'Dowd said the levels of OxyNorm in her system were higher than therapeutic but lower than toxic.
He suggested that Mrs Glackin had died as a result of multi-organ failure, secondary to a recent bout of Covid saying he did not believe the excess drug had a material effect on Mrs Glackin's death.
Giving his analysis, coroner Dr. Denis McCauley said the mistake in the dose of OxyNorm could be put down to human error when milligrammes were confused with millilitres.
However, he praised the nursing facility for giving full disclosure for what had happened to Mrs Glackin in her final days.
He added "Unfortunately, a mistake happened here, but immediately they came on board, recognised it and then acted on it which is the appropriate standard. That is now always achieved. In this case it was admirably achieved."
The court was also told that since the incident, Larissa Lodge has now put in place a number of operational changes to ensure that such an incident does not happen again.
All prescriptions are now carried out in milligrammes and one millilitre syringes are used to give controlled drugs.
A weekly review of drugs and medication audits are carried out each week.
New nursing employees must undergo two competency assessments prior to commencing their medication rounds and must also have medication management training.
Concluding Dr McCauley said he was satisfied that the dosage error did not have a "material effect" on Mrs Glackin's death.
The late Mrs Glackin's daughter Maureen was present at the inquest, and she indicated that she was very happy with how her mother had been treated at Larissa Lodge.
Dr McCauley found that Mrs Glackin died as a result of multi-organ failure as a result of persistent pneumonia.
He added that Mrs Glackin died of natural causes and thanked Larissa Lodge for their cooperation with the inquest.
Sympathy was expressed to the Glackin family by both the coroner and by Garda Sergeant Pauline O'Connor.