Aldwyn Jones, 90 was a resident of Byron House Nursing Home situated on the Wendover Road in Aylesbury in April 2006 when he was given a dose of 25 mls of the painkiller Oramorph rather than the prescribed dose of 2.5mls. Mr Jones died 14 hours after receiving the overdose.

At Amersham Magistrates' Court last week, county coroner Richard Hulett delivered a narrative verdict after a two day inquest into the death of Mr Jones, who had been living in Byron House Nursing Home in Aylesbury.

The verdict took into account Mr Jones's frail health, including a serious heart condition as well as a series of administrational errors relating to the dose of morphine Mr Jones was given by nurses working at Byron House in the hours before the 90-year-old's death.

A statement from Mr Jones's daughter Jennifer Adshead, 57 and her husband Peter, 59, read: "This tragedy was avoidable. This has caused the family great distress. We feel guilty we entrusted the care of a much loved father and grandfather unable to care for himself and with problems beyond the capability of the family to the hands of professional people who were entrusted with his care.

"The home, the management and the nurses have let him down, let the family down and raises a worry for all those who may be placed in their care. There was a complete failure of the duty of care owed to him, his family and the residents of the home."

Mrs Adshead added that her father was a Second World War veteran who was 'caring and had an excellent sense of humour' and 'a real zest for life well into his 80s.'

The coroner said that he agreed with the cause of death given by Dr Fegan-Earl, who carried out a post-mortem on Mr Jones's body and came to the conclusion he died due to a mixture of opiate intoxication and heart disease.

However, in his summing up, the the coroner criticised some of the systems used by staff at Byron House that led to Mr Jones being given a dose of morphine 10 times larger than it should have been.
Mr Hulett said: "The first mistake was with the faxing system. The possibility of things being misread and misused is inherent in this system.

"The second mistake was the checking of the delivery, and checking contents of the package in this instance was overlooked. This was the first instance in a catalogue of mischances and errors.

"The two nurses then recognised the bottle had the wrong dosage on it and gave Mr Jones 2.5ml instead of 25ml of Oramorph. In a sense it is an error as they departed from what was on the bottle and the MAR sheet but they were right about the dose.

"The overdose came about because of a combination of factors of communication at each stage," he added.

Sheila James, manager of Byron House Nursing Home said all procedures had been changed since the incident and two of the nurses involved had since left the nursing home.

On Tuesday, the inquest heard evidence from Nurse Ndebele and Nurse Simon who decided to give Mr Jones 2.5ml of Oramorph rather than 25ml which was written on the bottle.

However, Nurse Ndebele said that after a long night working she failed to mention this issue to the manager of Byron House during the morning handover.

As the problem with the dosage on the bottle had not been corrected, at 11am the next day (April 19) Bridget Evington and Ursula Perkins, two nurses at Byron House administered Mr Jones with 25mls of Oramorph.

Mr Jones, who suffered from dementia as well as heart disease, died in the early hours of April 20. Records showed that Mr Jones pulse and heart rate dropped in the hours after he was given the dose of 25mls of Oramorph.