A woman died following an overdose of morphine, which was given to her in error while in hospital.

A member of staff from Frimley Park Hospital was dismissed after administering the wrong dosage of pain relief to a patient, heard an inquest into the death of Kathleen Lee, 88, from Farnborough.

She was admitted to the hospital in July last year after her mobility had decreased. She was being treated for a urinary tract infection and was prescribed oramorph, a liquid form of morphine, for her knee pain, which was being administered to her daily in doses of 2.5mg.

However, on July 24, a nurse misread the prescription and accidentally administered 25mg which caused the patient to become drowsy and have problems with her breathing. She died six days later.

At the hearing at Woking on Tuesday (January 21), her son David said before being admitted to hospital Mrs Lee was not "in the best of health" and suffered from a number of illnesses.

He said: “She did tend to suffer from falls at home and had some difficulty in her mobility.

“We had some care in place for her, they came in three times a day, but she had problems with mobility and they often had to call the ambulance.

“It was normally connected with urine infections, which caused her some confusion, and she would be like that for a number of days until it cleared up.”


On July 8 she was taken to hospital following further problems with her mobility.

Mr Lee said he visited her a number of times that week, however, he had to go away on business and while he was away he was informed by his niece that Mrs Lee had been given an overdose and staff were taking appropriate action to try to improve her breathing and get her oxygen levels up.

He said: “A couple of times we thought she had improved but we tried ventilation systems and she didn’t respond well to that, then eventually she passed.

“I feel that the case is that, although mum had a number of underlying conditions, which she was being treated for, I do feel if she hadn’t have been given the overdose we would have seen her come out of hospital.

“How much life she would have had and how her quality of life would have been, I don’t know, but I do feel she would have come out of hospital on that occasion.

“It was all a bit traumatic for us at the end.”

Dr Francis Coyle, a diabetologist and endocrinologist consultant at Frimley Park, said it was uncommon for elderly people to be given a large amount of morphine and the standard maximum adult dose would be between 10 to 20mg.

She said the nurse that administered the dosage was under supervisory measures at the time but had been deemed competent to give medication.

Narrative verdict

She said the nurse did query giving the dosage but had asked another nurse on the ward. Dr Coyle said: “As far as I am aware, at no point did they approach the doctors to clarify this.”

The nurse’s conduct was reviewed following the incident and was dismissed from work immediately.

A post-mortem examination, carried out by pathologist Dr Norman Ratcliffe, showed Mrs Lee was significantly overweight, her heart was enlarged and she had emphysema.

Dr Ratcliffe said: “There was no morphine left in the blood. Given the history and my findings, I find it was impossible to ignore the fact she had been administered an overdose and that it might be this that did contribute to her death but I didn’t think it was the sole cause."

Belinda Cheney, assistant coroner for Surrey, recorded a narrative verdict and said the cause of death was respiratory failure, oromorph toxicity and acute exacerbation of chronic obstructive pulmonary disease (COPD), a collection of lung diseases.

She said: “The facts are very clear and nobody has disputed the facts.

“The hospital is really holding its hands up to the fact an error was made, the inability to treat it was compromised by the conditions that Mrs Lee had and she did not respond to treatment for the overdose.

“I am satisfied that the hospital has learned from this error.”