Inquest: Massive ketamine overdose not a factor in burns victim’s death

An inquest has heard that a massive overdose of painkiller administered to a burns victim did not contribute to his death.

Ben Steele (20) died within hours of a ketamine shower being given to him in Birmingham’s Queen Elizabeth Hospital.

He had suffered extensive burns after a spark from welding equipment caused an explosion in a shed at his Holbeach Clough home in late March 2012. He died on April 18 after five cycles of resuscitation following cardiac arrest.

Notes on Ben’s care had been reviewed by Dr Des Breen, an expert in analgesia and consultant anaesthetist at Sheffield Teaching Hospitals NHS Foundation Trust.
He told the inquest that Ben was showing signs of clinical deterioration in the 36 hours before his death.

The clinical care, he said, was “very good” bar the ketamine overdose administered by Dr Hozefa Ebrahim – said to be around five times the recommended level – but that was “110 per cent” not a contributory factor to Ben’s death.

Dr Breen added: “I’m surprised to hear expert witnesses that take a different view.”

He said while he could understand why Dr Ebrahim did what he did given Ben’s condition, no [medical staff grade] ST7 or consultant “would ever consider giving that dose” of ketamine. Dr Breen flagged up system failures which had allowed that to happen.

His view was that Ben died of heart failure and acute respiratory distress syndrome.

South Lincolnshire coroner Paul Cooper will deliver a narrative verdict on Thursday.(Dec 15)

In his summary at the end of last week’s two-day hearing, Mr Cooper referenced communication breakdowns on the day of the ketamine shower and conflicting evidence at the inquest between some medical staff.

Speaking after the hearing, Ben’s mum Tracey Steele-Kinder told The Voice: “I would like to take this opportunity to acknowledge all the support I have received from family and friends since the sad death of my son Ben.

“The coroner has now finally held an inquest some four and a half years after Ben’s death and concluded that whilst he was administered an excessive overdose of ketamine this did not cause his death, I still do not accept in my heart that a drug given seven times over the recommended dose could not have a major part to play.

“However, I have been told that since Ben’s death at the QE Hospital Birmingham, the drug administration protocol has been changed as a direct result from the incident so hopefully families in the future will not have to endure the torture I have been through.

“Now I can hopefully quietly move on with my life and I hope that everyone will permit me to do so, thank you.”

A statement issued to The Voice by University Hospitals Birmingham NHS Foundation Trust said: “The trust extends its sincere condolences to the family of Ben Steele.

“The distress Ben suffered as a result of the excessive dose of ketamine is a matter of profound regret to all those involved in his care.

“We hope that the early agreement to resolve the compensation claim and conclusion of the inquest, while of limited comfort, will help the family at this difficult time.”

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