A POISONS specialist has said he does not believe further treatment would have necessarily saved the life of a 21-year-old woman who died in a busy A&E department having overdosed on diet pills – but another expert disagreed.

Beth Shipsey had a seizure and went into cardiac arrest nearly four hours after arriving at Worcestershire Royal Hospital on February 15 last year, having overdosed on 2,4 Dinitrophenol, known as DNP.

Speaking at Worcestershire Coroner’s Court on Thursday (January 11), Simon Thomas, professor of clinical pharmacology and therapeutics, said staff could have done more but it was unlikely Miss Shipsey would have lived.

The court heard that the drug has no antidote and that clinicians must simply manage the symptoms, which can include high temperature and heart rate, as well as fever.

Prof Thomas is involved in the updating of TOXBASE, a database used by hospital staff across the UK when dealing with an unknown drug.

Neither the emergency doctor Alireza Niroumand nor the nurses who dealt with Miss Shipsey had heard of DNP, with the former admitting to failing to contact specialists directly through the system until minutes before the patient went into cardiac arrest.

The court heard earlier in the week that the emergency doctor had read through eight or nine pages of information on DNP from the database while treating Miss Shipsey.

However, two nurses who observed the patient in the resuscitation room soon after she was first treated, said Dr Niroumand did not inform them of the high potential for rapid deterioration.

Instead, they were told to simply perform cardiac monitoring, but agreed if they been aware of the likely severity of the patient's condition they would have acted differently.

But both failed to read through the literature provided on DNP from the database, which would have stated the inherent risks.

“There was no real understanding that Bethany Shipsey was in a life-threatening situation when she attended that emergency department,” said Prof Thomas.

He said poisons specialists would have warned staff that rapid deterioration could have occurred, as happened within the final hour before Miss Shipsey went into cardiac arrest at around 9.10pm.

But, he said the clinicians would have been told to simply closely monitor the patient and implement treatment, such as sedation, ventilation and cooling, as symptoms arose.

“I think that having reviewed the records, that sedation could have and should have been used earlier than it was. Whether that would have affected the outcome or not [it’s unlikely],” he said.

He said sedation would have reduced Miss Shipsey’s agitation sooner which could have helped to keep her temperature down for longer, but this was all speculation.

Prof Thomas also said that if he had been in the department, he would have had the patient moved to a high treatment or intensive care unit immediately, but said he did not know if there was space in either on the day.

And reiterated that this would not have necessarily increased Miss Shipsey’s chances of survival.

However, Professor Iain McIntyre, forensic toxicologist, said it is not known what a minimum safe dosage for any individual would be, however, someone who has acutely overdosed on DNP “can definitely survive”.

Prof McIntyre said Miss Shipsey had 8ml per litre of the substance in her blood at the time of death, according to the post mortem, with other people having survived with much higher levels present.

Coroner Geraint Williams asked him: “Had she had the full package of treatment earlier, she probably would have survived?”

Prof McIntyre said: “Correct. More likely than not, because of the blood concentration at the time of death being as low as it was.

“People with higher concentrations than Bethany have survived with treatment if it was provided in a timely and efficient manner,” he added.

Mr Williams asked if the data set on the drug is still too “insufficient for us to be precise about anything” to which Prof McIntyre agreed, but reiterated the importance of cooling measures being used.

The court heard that Miss Shipsey was in fact the first known reported person to die with only 8ml of DNP per 100ml of blood in her system.

Prof McIntyre said cooling measures, which could include ice packs being applied or an intravenous drip inserted, had proven to reduce toxicity by 50 per cent during animal testing.

Prof Thomas argued, however, that Miss Shipsey went from a stable condition, though with “abnormal physiology, to cardiac arrest in a very short time” – most likely due to the untreatable toxicity levels rising not because symptoms were not dealt with promptly.

And that how each patient copes with the poison in their blood, depends on the individual.

“What makes me believe that this was an episode that would produce death in spite of treatment was the rapid escalation [in her condition], especially in the last one or two hours of Bethany’s life.”

He said TOXBASE suggests only applying cooling measures when a patient’s temperature rises above 39 degrees and that Miss Shipsey’s was only measured close to that at 38.4 at around 8.50pm.

“When people are deteriorating like this, these methods are often very disappointing,” he added.

“The idea that by earlier intervention” you can reduce effects of toxicity, “that is not my experience”.

Barrister Michael Walsh, representing Miss Shipsey’s parents, Doug and Carole, questioned whether TOXBASE should therefore be updated based on this case, advising clinicians to begin cooling measures when patients are at much lower temperatures.

Prof Thomas said that could well be the case, as “TOXBASE is always evolving” and is updated on a constant basis.

Mr Walsh went on to say that “clinical features of concern” should have been noticed earlier by staff, meaning Miss Shipsey’s condition could have been more adequately managed.

Mr Walsh said the NHS Trust had admitted that hospital staff had failed to follow TOXBASE guidelines closely enough.

The court heard, Miss Shipsey’s temperature was not recorded by staff between 7.43pm, when it appeared normal, and 8.50pm, when it had risen significantly.

“Lots of measurements weren’t done,” said Mr Walsh. “Lots of measurements just weren’t taken.”

He suggested an “insufficient ECG” reading at around 7.15pm should have been repeated, while arterial blood gas readings should have been taken rather than from veins, as is advised on TOXBASE.

He posed the idea that much of this could have resulted in staff sedating Miss Shipsey sooner, which might have prevented the later convulsions she suffered, which slowed the incubation process as her oxygen levels dropped and she went into cardiac arrest.

“We have a watershed moment with the balance of this where more caution should have been taken,” the barrister said.

The court heard Miss Shipsey was given CPR for almost 50 minutes, but with her oxygen levels so low, the decision was eventually made to stop.

But Mr Walsh said there is evidence of patients who have gone into cardiac arrest in relation to taking DNP overdoses who have had CPR for three hours or more and gone on to fully recover.

Prof Thomas agreed that earlier sedation could have prevented the convulsions but argued oxygen ventilation was hampered by the high level of toxicity taking hold.

He said Miss Shipsey’s oxygen levels were so low after 50 minutes that staff had no option but to stop CPR.

“You can mitigate against that [her symptoms] to some extent” but “the underlying toxicity is still there,” he added.

Mr Williams went on to describe DNP “as one of the most extremely toxic” substances he had come across in his 30 years as a coroner.

“Anyone who takes this drug is acting very foolishly.

"It appears that overdose can result from even the smallest doses,” he said, before labelling it a “killer drug” and suggesting he would push to have legislation surrounding its availability altered.

Miss Shipsey had ordered it online from the Ukraine.

The inquest continues.