"Neglect" contributed to the death of a woman who was given the "wrong drugs".

Eileen McAdie, 65, died at Darent Valley Hospital in September 2016 after falling into a coma.

It happened after staff at Village Pharmacy in New Ash Green 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.

Eleven days after being given the drug The New Ash Green resident was rushed to the Dartford hospital, where doctors said she was confused and short of breath, and she later died of organ failure after being taken into intensive care.

Today, coroner Christopher Sutton-Mattocks has given a narrative verdict.

He said: "Eileen McAdie died on September 27 2016. Her death occurred 11 days after she was dispensed Amlodipine instead of Amitriptyline. The Amlodipine made a significant contribution to her death. Her death was contributed to by neglect."

Prior to his conclusion he said Mrs McAdie's GP and doctors at the hospital had acted properly and that the pharmacist had a responsibility to dispense the right drugs.

Mr Sutton-Mattocks recounted evidence given earlier stating that the drug Amlodipine lowers blood pressure, and that Mrs McAdie was already taking blood-pressure reducing tablets, along with other medication for health issues.

Furthermore Amlodipine has a tendency to accumulate in the system and the impact would have been exaggerated on Mrs McAdie because of her small stature.

The coroner added: "In my judgement the dispensing error on September 16 was a gross failure."

Yesterday, 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 Josiah 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.

After giving his verdict Mr Sutton-Mattocks asked what measures had been made to guard against future mistakes, and was told by Mrs Giltrow that a raft of steps had been taken. Posters had been sent to branches providing information; a sign-off sheet had been introduced, and a video was being produced to provide further training.

The coroner said it was clear processes had been "tightened up", adding: "in my judgement there's no realistic recommendation I can make which would have a realistic chance of making a difference."

Addressing Mrs McAdie's husband Ian McAdie, the coroner said: "You have been sitting there quietly and showing a great deal of courage listening to the evidence, which must have been very hard.

"Can I please pass on the condolences of the court to you and your family."

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