John Skinner
10 Feb 2022 · Coroner Graham Danbury · Hertfordshire
The coroner's concerns
1. overdose of phenytoin
“The Junior doctor [name redacted] 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”
Responses
No published response was found on judiciary.uk.