Inquest hears that 86-year-old King's Lynn woman dies with three and a half times the normal level of magnesium in her body
An inquest into the death of an 86-year-old woman after her bodily magnesium reached several times that of a normal level, saw that the Queen Elizabeth Hospital in Lynn has had four other magnesium related incidents.
Diane Marilyn Bance, of Lynn, was taken into the QEH in July last year with pneumonia.
The doctor on Stanhoe Ward noticed her magnesium levels were low, around 0.39, normal levels are usually around 0.7 to 0.9.
When she died Mrs Bance's levels were at 2.01, at their highest they reached 2.43 before the IV was removed.
Magnesium is an important electrolyte -a mineral that carries an electrical charge. It works with other electrolytes, such as sodium, potassium, and calcium.
Together, these electrolytes play a role in bone development, energy production, blood pressure regulation within the body.
Charge nurse Joy Sebastian said: "I saw Mrs Bance on July 31 during handover and when the second IV infusion had started, the doctor who prescribed it had mentioned that the IV was to stop in her notes."
Mrs Bance's daughter Helen Bance asked the coroner: "Why was a statement not taken from the nurses who administered the magnesium?"
"Before delivering an IV infusion the nurse should check on the computer system and query any anomalies
"I wanted to highlight that the nurse has a duty to check any doses and refer to the resources available such as the Medusa system, which is used to keep track of it."
The family had also requested records of other magnesium related incidents, although these did not result in death, it was found that the QEH had four other instances of magnesium related incidents in the last three years.
However it was noted that these "were different to the case of Mrs Bance and treated as minor incidents".
The coroner, Simon Milburn, asked the doctor present on Stanhoe Ward about the actions taken when it was noted that Mrs Bance has low magnesium levels.
The doctor said: "I noticed her levels were low, but instead of prescribing IV magnesium straight-away I referred to the consultant on duty for advice.
"Mrs Bance had acute kidney injury, so I wanted to get his go ahead before proceeding with the IV.
"Magnesium is important because during treatment, the other electrolytes will not regulate without it. The consultant on duty advised that I proceed to give treatment.
"Following NHS guidelines I prescribed the IV for 48 hours subject to a blood test to check the levels. With low magnesium a patient could be at risk of seizures and other health complications. It was decided that the patient was at significant risk."
The matron on duty confirmed that the consultant, Dr Bhala, was not a specialist, but a general medical consultant.
She said in her statement: "The death of Mrs Bance was avoidable, and no further treatment was given at the time after discovering the levels had gone up higher than they should.
"The consultant was not a specialist, which means that the patient's renal impairment was not considered in the same way. The nurses on duty would not have had any concerns as the prescription was laid out very clearly by the doctor."
It was confirmed that Mrs Bance had a heart blockage, secondary to hypo-magnesia and this was recorded as the medical cause of death.
She was moved to the ICU department where doctors informed her daughters that comfort and care should be their priority instead of treatment.
Mr Milburn concluded that the death was due to "misadventure".
He said : "The cause of death was hypo-magnesia caused by misadventure. This means treatment was given and as a result of that treatment the course of a natural disease was altered unintentionally."
