A woman who was given the "wrong prescription" before she died had an abnormally low blood pressure, an inquest heard.

Eileen McAdie, 65, died at Darent Valley Hospital, in Dartford, on September 27, after falling into a coma.

It happened after staff at Village Pharmacy in New Ash Green allegedly gave her the wrong drug to deal with her shingles.

Mrs McAdie went to the pharmacy a week before her death to pick up a prescription of Amitriptyline. However, the drug she received was a box of Amlodipine, but with an incorrectly printed label for Amitriptyline.

The New Ash Green resident was rushed to the Dartford hospital before midday where doctors said she was confused and short of breath.

Speaking on the second day of the hearing, Dr Shivan Kanani, who treated the patient at Darent Valley, said he noticed the wrong label on he box and that McAdie had an abnormally low blood pressure.

He said tests showed the patient’s blood pressure was 80 over 50, when a healthy person's pressure would be between 120 to 180.

Mrs McAdie also took a mental awareness test, scoring 8/10, when most patients are expected to get 10/10.

Dr Kanani, who had been qualified for ten years at the time, diagnosed that the patient had an acute kidney problem and pneumonia and gave her antibiotics. Mrs McAdie remained in hospital when he finished his shift at 9pm.

The next time he heard about Mrs McAdie was a couple of days later when he was informed she was in intensive care.

Jackie Giltrow, medication safety officer for Paydens Group, which runs the Village Pharmacy and John McConnville, superintendent pharmacist with the group, were both called to give evidence during the hearing.

They spoke about the already known risk of "lookalike and soundalike" drugs that staff are at risk of mixing up. Amitriptyline and Amlodipine were both high on this list of mix-up drugs.

Both witnesses were asked what has been done to stop this sort of tragedy happening again. Mrs Giltrow mentioned a warning about these drugs was sent out in a monthly newsletter, just a couple of weeks prior to the incident.

However, when questioned by family barrister James Robottom it was revealed the newsletter was read by pharmacist Mr Ghartey Reindorf, but not disseminated to other staff members at the Village Pharmacy.

Mr Ghartey Reindorf was later moved from the New Ash Green pharmacy to Chatham and Mr McConville revealed that when he was informed of Mrs McAdie’s death he was ‘devasted’ because he knew her as a regular customer.

The inquest continues.

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