Chesterfield pensioner died after being given six times the prescribed dose of morphine, an inquest hears

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The family of a woman who died as a result of a series of errors in her care say they intend to take legal action against the parties criticised in a coroner’s report.

Arlene Devereaux was given tablets containing six times the prescribed dose of morphine after pharmaceutical giant Boots sent 60mg tablets when it should have sent just 10mg pills, an inquest at Chesterfield coroners’ court was told.

The mistake was not spotted by staff at Springbank House Care Home on multiple further occasions despite stringent rules regarding the administration of controlled drugs.

A verdict of accidental death was recorded by coroner James Newman - but Mrs Devereaux’s daughter, Sonia, 49 , of Inkersall, said: “The chain of errors is unbelievable.

“The verdict was accidental death but the coroner told us that it was not that kind of accident. We have spoken to our solicitors and we will be making a civil claim both from Boots and the home.”

She spoke of the ‘mental torture’ the case had put her through and said her and her family had been ‘through hell and back’.

She said: “I am not the same person as I was before this happened.

“I have had counselling and I even had thoughts of taking my own life - I just wanted to be with my mum.

“There’s some relief now - we can find some closure.

Her mother died at Chesterfield Royal Hospital at 2.40am on November 30 2012 - the day of her 71st birthday.

She was initially admitted to hospital with a suspected stroke but at 6pm on the night before she died the care home realised its mistake.

The court heard from witnesses who were questioned as to how the mistake may have been made.

Pharmacist John Barber, now retired, said: “All I can think is that I was interrupted somewhere in that process.”

“I really don’t know. It’s been playing on my mind ever since.”

A compliance officer for Boots said in a written statement that the stronger dose was dispensed ‘as a result of human error, and had the company’s standard operating procedure been followed it would not have happened’.

Care home manger, Dorothy Mbulo described the strict ‘two person checking policy’ that the home employed, a policy which fell apart over two days before Mrs Devereaux fell seriously ill.

In recording his verdict, Mr Newman said: “Despite there being clear opportunities available to correct the medication error from the start, it was not identified and resulted in an acute morphine overdose that had a clear and primary role in Mrs Devereaux’s death.”