Jersey hospital could make pharmacy changes after death
Susan Smith collapsed last summer hours after leaving hospital with suspected gall stones.
Doctors had not realised she also had severe liver disease.
Mrs Smith's liver was not able to cope with the mixture of painkillers and drugs she had been taking.
'Keen to leave' The inquest was told tests, which included an ultrascan, revealed gall stones and also that her liver was slightly larger than normal.
She was discharged on the Sunday morning and prescribed a six day course of tremadol but on half the normal strength. She was booked in for an operation.
She seemed keen to leave hospital according to her husband Keith, who said later that day she was not feeling well and would not settle.
Late that night she collapsed and was pronounced dead in hospital.
The tremadol, a strong opiate, also had a reaction with the antidepressant she was taking, causing further problems.
The inquest said the reaction and heart problems lead to her death.
Hospital pharmacist One of the consultants that gave evidence on Friday, Dr Enders Kuypers, said the outcome could have been different if she had been admitted to a medical ward rather than a surgical one where they thought they were treating gall stones.
Because Mrs Smith was admitted on a Friday and was discharged on Sunday, she was not visited by a hospital pharmacist.
Pharmacists visit wards on weekday mornings and are there to check the drugs prescribed to patients are appropriate, effective and are not going to react with other medication.
The inquest heard from Chief Pharmacist, Paul McCabe, who said if a hospital pharmacist had been on a ward round that weekend, they would have flagged up possible problems with taking both the antidepressant drug and tremadol.
Dr Andrew Luska, Joint Medical Director, said staffing arrangements could be changed to allow hospital pharmacists onto the wards at weekends instead of just weekdays.