Mental health nurse cleared of manslaughter in overdose case
A nurse has been found not guilty of killing a patient by giving him 14 times the amount of anti-psychotic drugs he was prescribed.
Mental health nurse Amanda Young, 40, was instructed to administer 300mg – a little more than a teaspoon – of clozapine to Joshua Gafney, 22, at his home in Yeovil, Somerset.
Young “did not see” details of the medication’s strength written on the label and instead poured six bottles into a glass for him, leading to a fatal overdose.
The experienced nurse told Bristol Crown Court she believed each 14ml bottle contained 50mg of clozapine when it fact this figure was per mililitre – meaning one actually contained 700mg.
Mr Gafney drank the glass – containing 84ml or 4,200mg of clozapine – and was pronounced dead two hours later, having been found in bed by his mother and sister.
A post-mortem examination later established the cause of Mr Gafney’s death as acute clozapine toxicity, confirming he had been the victim of a “massive overdose”.
Young, of Tewkesbury in Yeovil, Somerset, denied the manslaughter of Mr Gafney by gross negliegence on the date of his death, February 8 2012.
A jury of five men and seven women today found her not guilty of the charge following a three-week trial at Bristol Crown Court. Young, who had previously given Mr Gafney the medication, visited his home in Yeovil with colleague Petia Gummer, a trained nurse, at 7pm.
“I was adamant that my mathematical equation was correct,” Young told the court. “I had no doubts about the dose I was giving.”
Mr Gafney and his mother, Tina Marren (pictured, right), were present at his home when the nurses arrived and Young asked for a glass to pour the medication in.
Mrs Marren questioned the dose but was reassured when Young showed her a bottle of the medication.
Mr Gafney usually took 700mg of clozapine – one bottle – to treat his paranoid schizophrenia.
However, in February 2012 he stopped taking the medication for a number of days and his tolerance to it had to be built up slowly again in a process called titration.
On February 3, Young first administered his reduced dose but gave him 175mg or 3.5ml instead of the prescribed 12.5mg or 0.25ml. Young said she had seen the amount 50mg written on the bottle, which in fact read 50mg/ml.
Throughout the titration process, Mr Gafney was given medication by Young and two other nurses – all of whom made mistakes with his dosage.
Young said she would not have given Mr Gafney six bottles of medication if she had been made aware that he had been taking just one before the titration process.
“I would have stopped what I was doing straight away,” she said. “I remember thinking ‘I am giving the correct dose, I have checked the date, I am confident with the dose’.”
Young and Ms Gummer left Mr Gafney’s home and he soon went to bed, where he was discovered lifeless by Mrs Marren about 45 minutes later.
Paramedics were called but Mr Gafney was pronounced dead at 9.07pm. The following morning, Young returned to work to discover the tragic news and immediately checked the dose with colleagues, who reassured her it was correct, she said.
“I was very honest, I said I had given six bottles,” Young said. “I became tearful because Joshua was very young. You don’t want any one in your care to die.”
A colleague later phoned Young, who had returned home, to let her know it appeared that she had made a mistake with the medication. “At that stage my heart sank,” Young said.
Outside court, Mr Gafney’s family spoke of their devastation at hearing the not guilty verdict.
“Joshua was gentle, caring, kind and with a big heart. We will never be able to see the happy life Joshua should have had and deserved because this was very sadly taken away from him,” they said in a statement read by police.
“Although he was ill he fought every day to get better. We are very proud of Josh because he showed huge signs of improvement. This has destroyed our family’s life and we will never forget him.
“His memory is close to our hearts. It has taken a long time but as a family we appreciate the many who have supported us throughout. David Laws MP was a huge help. He has shown great kindness which we will never forget.
“The police have worked extremely hard on our behalf and we will always be grateful. We still do not understand why Somerset Partnership NHS Trust, who employed Amanda Young, have not apologised to us or accepted responsibility for Josh’s death.
“As a family we are devastated with the not guilty verdict. Joshua was taken away from us and we only wanted justice for him. We already knew how he died and we heard that in court.
“This verdict means that no one now has been held accountable for his death over three years on. There will now have to be a full inquest and we will have to find the strength to carry on.
“We will try to move on but it will be hard knowing that the person who gave him the drugs that killed him has not been punished.
“We will always remember Joshua for the lovely person that he was. We will remember how he loved fishing with his uncles, how he loved going camping.
“Joshua loved his music and spending time with his friends and family. Because of his illness he was just starting to live his life. This was taken from him too soon. However, we are grateful that he had the time to make some happy memories.
“Josh was looking forward to becoming an uncle but unfortunately did not have the chance to meet his beautiful nephew Leo. We will tell Leo many wonderful things about his uncle Josh and we know that Josh would have loved him very much.
“Before Josh died he and his sister lost their father. We would like to think they are together looking after each other and they are both at peace. Rest in peace Joshua, you will always be in our hearts.”
Detective Inspector Lorna Dallimore, from Avon and Somerset Police, said: “At the time of his death Joshua Gafney was suffering from poor mental health, a condition that was being managed with medication in the community.
“Notwithstanding that Joshua Gafney was administed a toxic level of clozapine resulting in his death, the jury today determined that mistakes in it’s administration did not ammount to gross negligence manslaughter.
“The prosecution of health professionals for gross negligence manslaughter is rare and the threshold for criminal prosecution is high.
“We would like to thank the jury for their careful and considerate deliberations in this complex and tragically moving case. Our thoughts are with the family of Joshua Gafney, who for the past three years struggled to discover the truth of what happened to Joshua.”
Copyright (c) Press Association Ltd. 2015, All Rights Reserved. Picture (c) Benjamin Wright/PA Wire.
