Deceased
Sharyn Kaine
Demographics
73y, female
Coroner
Coroner Archer
Date of death
2021-10-09
Finding date
2024-09-16
Cause of death
Multi organ failure due to adhesions related bowel perforation (surgically treated) and paracetamol-induced liver failure
AI-generated summary
Sharyn Kaine, a 73-year-old woman, died from multi-organ failure due to adhesions-related bowel perforation and paracetamol-induced liver failure. She was prescribed intravenous paracetamol 1g four times daily post-operatively, despite weighing only 39kg. The appropriate dose should have been 487-585mg. A junior doctor transcribed the original prescription into the digital medication system without detecting the error, and subsequent clinical teams failed to review the dosing. Paracetamol was administered intravenously 13 times over five days before liver failure developed. Key clinical lessons include: weight-adjusted dosing must be consistently applied; intravenous medications require 24-hourly review; liver function should be monitored when high-dose paracetamol is given; and electronic prescribing systems with built-in safety alerts are essential to prevent medication errors.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
43y · Female·Severe diffuse hypoxic brain injury caused by administration of supratherapeutic…
A 43-year-old woman died from severe diffuse hypoxic brain injury caused by excessive sodium bicarbonate administration during treatment of amitriptyline overdose. The treating ED consultant prescribed sodium bicarbonate…
79y · Female·medication related cardiac arrest (verapamil and propranolol) in a patient with …
Mrs Patricia Croxon, a 79-year-old admitted with community-acquired pneumonia, died from medication-related cardiac arrest caused by verapamil and propranolol. The verapamil was charted in immediate release form when she…
57y · Male·streptococcus pneumonia septicaemia due to splenectomy
Maarouf El-Cheikh, a 57-year-old man with splenectomy history, presented to Calvary Hospital ED with sepsis on 21 March 2016 and died 22 March 2016. Expert review identified multiple sub-optimal care deficiencies: inadeq…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.