Spot checks are being carried out on wards at Bradford Royal Infirmary to ensure nurses giving intravenous drugs are sticking to a ‘double-checking’ policy.

Bosses at Bradford Teaching Hospitals NHS Foundation Trust say lessons have been learned after a woman patient was given ten times her prescribed sedative dose by a busy nurse.

The Trust triggered a ‘serious untoward incident’ investigation on June 25, 2011, when it was discovered terminally-ill Maureen Njume, 36, of Dirkhill Street, Great Horton, had been injected 15mgs of the tranquiliser drug Haloperidol instead of 1.5mgs to stop her being agitated.

At an inquest into Miss Njume’s death, Assistant Bradford Coroner Dr Dominic Bell said nurse Susan Wright (nee Holdsworth) had mistakingly believed each of the three vials she administered to the HIV patient on the infectious disease ward at the end of a busy night shift had only contained 0.5mgs.

He also noted the nurse had deviated from Trust policy by not getting the dose double-checked because of the urgency it was needed and her “unwillingness to involve a colleague she believed had been less than helpful with similar duties earlier in the shift.

Police carried out an investigation into Miss Njume’s death but the Crown Prosecution Service decided no further action was necessary.

Recording a narrative verdict Dr Bell said the mother-of-one was so ill she had only hours left to live and, according to experts, the overdose of Haloperidol would have only slightly hastened her inevitable death.

He said: “Her death occurred within 30 minutes of the intravenous administration, at approximately 8am, of 15mgs Haloperidol. The administration of 15mgs of haloperidol represented a drug administration error against a background of 1.5mgs of this agent being prescribed for the control of agitation.”

Dr Bell also said he was satisfied there had been a robust analysis by the Trust of what happened and remedial measures implemented and audited.

After the hearing a Trust spokesman said it had carried out its own investigation which signalled its determination to improve patient care and safety by learning lessons and minimising any potential risk of something similar happening again.