Inquest Into The Death Of Sharyn Kaine
Deceased
Sharyn Kaine
Demographics
73y, female
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.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Prescription of weight-inappropriate paracetamol dose (1g QID for 39kg patient)
- Transcription error or failure to incorporate anaesthetist's dose correction into digital medication record
- Failure to review paracetamol dosing between 3-7 October 2021
- Absence of organisational procedures or guidelines for paracetamol administration at TCH
- Lack of weight-based dose checking functionality in EMM system
- No 24-hourly review of intravenous paracetamol administration
- Delayed liver function testing (first test on 6 October, four days post-surgery)
- Clinical teams did not detect the dosing error despite subsequent medication reviews
Coroner's recommendations
- CHS should publish statistical material identifying trends in adverse medication outcomes (including non-fatal outcomes) at TCH since introduction of the DHR, specifically including adverse outcomes involving paracetamol, to demonstrate the efficacy of the DHR system
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