Sneh Chaudhry
PFD Report
Historic (No Identified Response)
Ref: 2018-0182
Coroner's Concerns (AI summary)
Drug confusion due to similar vial appearance between Fungizone and Ambisone, combined with passive nursing checks, created a risk of administering the wrong, more toxic medication.
View full coroner's concerns
(1) Fungizone and Ambisone have a similar drug vial appearance and can be confused. Fungizone is typically used as aerosol and Ambisone as an intravenous preparation: Fungizone has a smaller therapeutic window and is more toxic and may lead to a fatal hyperkalaemia as in this case (2) The nursing checks were described as passive rather than active
Sent To
- NHS England
Response Status
Linked responses
0 of 1
56-Day Deadline
2 Sep 2018
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 22/10/2017 commenced an investigation into the death of Sneh Lata Chaudhry aged 56 years The investigation concluded at the end of the inquest on 04/06/2018. The conclusion of the inquest was Sneh Lata Chaudhry died from immediate complications following administration of an incorrect formulation of amphotericin. The Medical Cause of Death was 1a Hyperkalaemia following amphotericin administration 1b multiorgan failure following high risk coronary surgery Ic triple vessel ischaemic coronary disease off pump coronary artery bypass grafting 4/10/2017 II Diabetes mellitus, morbid obesity and asthma
Circumstances of the Death
Ms Sneh Latta Chaudhry had high risk coronary bypass grafting on the 4/10/2017 at Harefield Hospital with a prolonged stay in ITU. She developed a systemic candida infection. She required treatment with amphotericin: The wrong preparation of intravenous amphotericin was given (Fungizone rather than Ambisone). An HCA obtained the wrong preparation from the ward drug stock: The administering nurse and the checking nurse did not notice that the wrong preparation was obtained and then administered. The drug vials have a similar appearance.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.