Paolino Amico

I am Sonia Hayes, Area Coroner, for the coroner area of Essex

On 18 June 2024 an investigation was commenced into the death of Paolino  AMICO, aged 63 years. The investigation concluded at the inquest on 3  November 2025. The conclusion of the inquest was a Narrative: Mr Amico’s  death from Metastatic Bladder Cancer was hastened and contributed to by  multiple morphine overdoses between 10 and 11 June 2024 due to a  prescription error that was not scutnised. Morphine reversal and subsequent  pain relief was not managed according to the guidelines and Mr Amico suffered acute withdrawal syndrome. Medical cause of death of ‘1a Type 2 Respiratory Failure 1b Community  Acquired Pneumonia, Inadvertent Morphine Overdoses and acute withdrawal syndrome 1c Metastatic Bladder Cancer with Advanced Clinical Frailty

Paolino Amico had a history of metastatic bladder cancer that had not  responded to treatment on a clinical trial. Mr Amico was discharged from  hospital on 29 May 2024 and was oxygen dependent. Mr Amico developed  severe bilateral pneumonia and was admitted into Princess Alexandra Hospital on 9 June 2024 and treated with antibiotics , nebulisers and fluids. Mr Amico was not seen in person by a doctor who altered his prescription in the emergency department on 10 June. On the afternoon of 10 June Mr Amico’s  medication chart was not scrutinised when he had a medical review as he was  deteriorating. Due to a prescription error Mr Amico received multiple overdoses  of a controlled drug morphine sulphate (slow release) on 10 and 11 June 2024  resulting in morphine accumulation that was partially reversed with naloxone on 11 June. Mr Amico was not deemed suitable for admission to intensive care for  Naloxone infusion. Mr Amico died on 12 June 2024 at Princess Alexandra  Hospital as a consequence of Type 2 Respiratory Failure due to Community  Acquired Pneumonia and Inadvertent Morphine Overdoses with Metastatic  Bladder Cancer with Advanced Clinical Frailty.There was a delay in raising a  medical emergency when Mr Amico had elevated NEWS score of 10 and his  morphine reversal and pain relief was not managed according to the guidelines  and he suffered acute withdrawal syndrome.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. (1) The consultant required a discharge plan for oxygen therapy to be in place before Mr Amico could go home. The hospital discharge plan and medications  were  confusing  and  the  referral  for  oxygen  therapy requirement was unclear, and the PAT testing for the machine was out of date. Paramedics advised the family that the oxygen provided on Mr Amico’s  discharge  was  low  flow  and  was  not  meeting  his  oxygen requirements with his oxygen saturations at 68% and this immediately improved on ambulance crew equipment. (2) Mr Amico did not receive his prescribed medications during his second admissions when he was readmitted to hospital on 9 June. a.  On 9 June a doctor in Accident & Emergency had reviewed Mr Amico’s prescribed medications and increased liquid oral morphine sulphate 10 mg in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 hours with slow released morphine sulphate (MST) continued 2 times daily. Trust staff did not administer any morphine to Mr Amico although he and his family were raising concerns about his high level of pain. b.  The  family  was  informed  incorrectly  that  medications  had  not  been prescribed. On the morning of 10 June, the family were given permission by a nurse to dispense from Mr Amico’s own supply of medications that he had brought to the hospital due to his level of pain. This was not accurately recorded in Mr Amico’s record. Mr Amico took his prescribed morning dose of MST. c.   On 10 June the nurse in Accident & Emergency did not escalate to the nurse in charge or a senior doctor that she could not locate the doctor allocated  to  Mr  Amico  and  instead  approached  a  foundation  year  1 doctor to prescribe pain relief for Mr Amico. The nurse informed the doctor who was junior and very busy that the frequency of the morphine needed to be increased for Mr Amico. The doctor did not escalate the matter and did not review Mr Amico before prescribing a controlled drug. d.  Neither the nurse nor the  doctor  sufficiently scrutinised the medication prescribed on 9 June or on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily. Mr Amico was not referred for pain management. e.  Mr Amico then moved to a ward. Multiple    nurses were involved in checking and administering a controlled drug morphine sulphate slow release (MST) on 5 separate occasions between 10 and 11 June 2024 and did not raise concerns about the potential for a prescription error or note that Mr Amico had already received 1 dose of MST that morning. (3) Mr Amico’s NEWS score increased, and an emergency call was not put out on 11 June when it was established that Mr Amico was unresponsive even to pain from 03:00 hours . (4) The on-call doctor was called approximately one hour after Mr Amico’s NEWS score was found to be 10 and arrived at 07:50, this was not an emergency call. The on-call doctor had not been informed of: a.  the deterioration in Mr Amico’s presentation during the night b.  that the family had informed nursing staff of their concerns Mr Amico had been given the wrong medication when he was noted to be unresponsive  at  approximately  03:00  hours,  that  should  have immediately raised concerns about an overdose of MST. (5) The on-call doctor escalated concerns immediately but not emergency call was put out. (6) Mr Amico morphine overdose was partially treated: a.  There  was  an  immediate  response  to  Naloxone  but  the  opioid reversal for overdose was not in accordance with British National Formulary guidelines or with an NHS England alert previously issued. b.  There was no consideration or plan for alternative pain management in a patient who had been receiving morphine pain relief as part of his treatment plan for cancer. c.   Mr   Amico   suffered   acute   withdrawal   syndrome   and   family complained about his suffering to hospital staff that they stated was not  ameliorated.  An  emergency  call  would  have  triggered  the attendance of an Anaesthetist who could have given advice on opioid reversal in a palliative patient. Princess Alexandra Hospital & NHS England (7) Multiple nurses were involved in morphine administration and all had completed their original training outside of the UK and had undertaken a Trust medicines administration training that should have recognised that the prescription of MST 4 times a day was not appropriate. Mr Amico received 6 doses of MST in less than 24 hours instead of 2. (8) Medicines administration refresher training for nurses is not mandatory and  the  Trust  in  reviewing  this  case  has  not  followed  a  local recommendation from senior nurses for this to be included.

In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action.