HOSPITAL bosses have been ordered to take urgent action after a pensioner died from a vitamin overdose after a catalogue of errors.

Irene Whittingham died in the Royal Bolton Hospital from a vitamin D overdose on July 31 at age of 86, just months after wrongly being prescribed a “high dose” of the vitamin.

Instead of taking the dose twice a week ­— she was prescribed it twice a day.

A coroner, who concluded the death was caused by an accident contributed to by neglect, has said that there is a risk of future deaths if action is not taken.

Errors in the prescription happened when Ms Whittingham was admitted to the Royal Bolton Hospital in March last year with seizures. Investigations, as part of her treatment, revealed that she had low vitamin D levels.

A specialist recommended “20,000 international units” of the vitamin to be given twice a week for three months.

But in error, it was recorded that the supplement be given once a week. In the second error, the ward pharmacist picked up on the initial mistake but amended it for the medication to be given twice daily.

And no advice was given about blood monitoring while she was “being loaded on a high dose of vitamin D which exceeded the national guidelines”.

Mrs Whittingham, who had underlying health conditions, was discharged less than a month later with her prescription dispensed in the community.

She was readmitted back to hospital in June for acute kidney injury and vitamin D toxicity. Her condition failed to improve and she died.

Now the coroner who conducted the inquest into Mrs Whittingham’s death has issued a “prevention of future deaths” report to The Royal Bolton Hospital.

It was found that conflicting guidance is provided to clinicians when vitamin D blood monitoring should be undertaken. One consultant gave evidence at the inquest into Mrs Whittingham death that he expected blood level monitoring to take place within four weeks of the “loaded vitamin D commencing “ and the endocrinologist gave evidence that he expected such monitoring to take place around the “three month period”.

Rachel Syed, assistant coroner, stated: “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.

“No advice or instructions were issued to the the deceased’s GP, regarding any requirement to monitor the deceased blood levels whilst she was in the community and taking high levels of vitamin D which exceeded national guidelines.

“I request that the chief executive of The Royal Bolton Hospital reviews the guidance and practices being adopted by staff, in regard to blood monitoring of the above types of patients show take place to ensure a consistent and safe approach is adopted.”

The coroner also requested that software be improved to ensure better system safety nets are put in place to "prevent catastrophic prescribing errors occurring in the future."

Ms Syed added: “In my opinion urgent action should be taken to prevent future deaths and I believe that you have the power to take such action.”