Hailsham father died after ‘catastrophic error’ with prescription
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Nicholas Eaton was told to take ten times the amount of pain relief medication than he should have been, an inquest at Eastbourne Town Hall heard on Thursday (September 24).
“I have been left with four children with no father,” his wife Teresa Eaton said at the inquest.
A criminal investigation was launched into Mr Eaton’s death on the grounds of manslaughter by gross negligence, but the case did not meet the very high criminal standards set to pursue it in the courts.
The 55-year-old painter and decorator had been placed on methadone as his regular medication pethidine was unavailable due to a shortage, the inquest heard.
However, Hailsham Medical Group pharmacist Hashem Soozandehfar made a fatal mistake in his calculations when advising how much Mr Eaton should take.
The inquest heard Dr Soozandehfar had believed the methadone to be equivalent strength to the pethidine, which Mr Eaton had been taking for many years for back pain following a collision.
But in fact, 5mg of methadone was the equivalent of 50mg of pethidine, the inquest was told by pathologist Zainab Ali.
Days after taking the new medication provided by Seaforth Pharmacy, Mr Eaton was found dead in his home by his son, on November 6, 2019.
Dr Ali’s post mortem report found he had died due to a combination of chronic obstructive pulmonary disease and methadone toxicity.
The inquest heard a statement from Mr Eaton’s daughter Karly. She said before the change in medication her father’s health was the ‘best he’d been for some time’.
But when he began taking the methadone, the shift in his wellbeing was evident, she said, with her dad being more tired, drowzy, and finding it difficult to walk.
After his death, she saw the methadone medication leaflet warned not to take it if the person had a lung condition, which he did.
“I was concerned as to why it had been given to him,” she said.
Representatives of the health group were asked what measures had been taken to make sure this never happened again.
GP Sabina Spencer said the policy had been ‘thoroughly checked’ following Mr Eaton’s death and a number of improvements made. When asked if the policy would allow a similar mistake to happen in the future, she said no.
Dr Soozandehfar said he had been instructed to take a course and that the CCG had produced a leaflet with advice to pharmacies on medication conversions.
He had been interviewed under caution by police, the inquest heard, but the Crown Prosecution Service (CPS) found the case did not meet the criminal threshold.
Police said, to do so, the individual would have to show no consideration towards the person’s life, and Dr Soozandehfar had previous good character and had made a fatal but unintentional error.
“What you gave him was in fact 10 times the amount it should have been,” said coroner Alan Craze.
He said, “It was catastrophic error as is recognised by everybody in this room.
“But we can’t change history sadly. This error wasn’t made deliberately, it wasn’t made criminally.”
He reached a conclusion of medical prescription accident and expressed his condolences to the family.