A 55-year-old woman tragically died from liver failure after being accidentally prescribed a lethal double dose of painkillers containing paracetamol at a major London hospital, a coroner has concluded.
A Fatal Sequence of Errors
Paula Doreen Hughes was admitted to the Queen Elizabeth Hospital in Woolwich, south-east London, on 6 January 2022 after fracturing her upper arm bone. During her treatment, doctors mistakenly prescribed her two separate medications both containing paracetamol: standard paracetamol and co-codamol, which is a combination of paracetamol and codeine.
This critical duplicate prescription was issued on three or four separate occasions between her admission on the 6th and 8 January 2022. The erroneous prescription was not removed from the hospital's electronic system until approximately 2.30pm on 8 January.
Missed Symptoms and a Delayed Diagnosis
Mrs Hughes's condition began to seriously deteriorate around midday on 8 January. Despite this, medical staff failed to identify that she was suffering from a paracetamol overdose until the following morning. By that time, she had already been transferred to intensive care with fulminant acute liver failure, a severe condition often triggered by drug toxicity.
The inquest, held by Coroner Liliane Field for London Inner South on 14 October 2025, found this delay meant Mrs Hughes did not receive a timely dose of n-acetyl cysteine, the antidote for paracetamol poisoning that could have saved her life.
She later died at the Queen Elizabeth Hospital. The causes of death were recorded as liver failure and paracetamol overdose, with ischaemic heart disease, a urinary tract infection, diabetes mellitus and excess alcohol consumption also listed as contributing factors.
Systemic Failures and a Call for Action
The coroner's investigation identified multiple points of failure. Two prescribing doctors, two nurses, and a pharmacist all overlooked the duplicate prescription. Furthermore, staff did not ask Mrs Hughes if she had taken any other medication prior to admission, so they were unaware she had already taken an over-the-counter dose of paracetamol.
The inquest also found that medical staff failed to recognise her "state of confusion," which, if acted upon, could have led to quicker intervention.
In a formal Prevention of Future Deaths report, Coroner Field has called upon Lewisham and Greenwich NHS Trust, NHS England, The Royal Pharmaceutical Society, the software provider Cerner, The Medicines and Healthcare products Regulatory Agency (MHRA), and The Royal College of Physicians to respond with action plans within 56 days.
The Trust has since stated it plans to implement new safety systems. These proposals include introducing a hard stop in the electronic prescribing system to flag duplicate medications and enhancing staff training to better identify signs of patient confusion.
