An elderly woman died after being “chronically” over-prescribed Vitamin D tablets at a care home, an inquest has heard.
Eileen Cowles, 86, who weighed just seven stone at the time of her death, was taking two capsules of colicalciferol each day containing a total of 40,000 units of Vitamin D.
However, a hearing at Wakefield Coroners' Court on Monday was told the pensioner should have been receiving two tablets a month, not every day.
Her family only discovered the error after finding papers while clearing out her room at Primrose Court care home in Guiseley, West Yorkshire, following her death in April 2015.
It was found she died of intestinal bleeding caused by the high levels of calcium in her blood as a consequence of the over-prescription, the coroner heard.
Pathologist doctor, Richard Shepherd, told the inquest he had not seen such an extreme case of hypercalcemia – high levels of calcium in the blood – in his 35-year career.
“I considered the exact cause of intestinal bleeding was more likely than not related to the hypercalcemia,” he said.
“I don't think I've ever come across hypercalcemia in this way before. I could not find any natural reason why there was raised calcium levels.”
Ms Cowles began taking a low dosage of colicalciferol twice a month to improve bone strength after she fractured her left hip following a fall at home in September 2014.
But, when the former landlady moved to Primrose Court a month later, her GP changed and a note from the practice instructed she simply “take two” tablets without any indication as to how frequently.
Her “high” dosage levels were queried by both care home staff and pharmacists at Boots, who were told to give Ms Cowles two tablets per day. Several repeat prescriptions were made at the same dosage.
Her condition began to deteriorate and she was admitted to Bradford Royal Infirmary in March 2015 and then Leeds St James Hospital later that month, where it was noted she had raised calcium levels.
GP Ibrahim Syed told the inquest the dosage was a “mistake” and he would have scrutinised the repeat prescription in more detail if he had more time.
“I think it’s human error,” he said. “It's a case of having to scan a large number of prescriptions every day, compounded by trust I put in my colleagues.
“I think when you are less pressed for time it might be I would have been able to spot the erroneous dose. It was almost like a needle in a haystack.”
The inquest, which is due to last three days, continues.
Additional reporting by SWNS