Deceased
OS
Demographics
5y, male
Coroner
Decision ofDeputy State Coroner Magistrate Derek Lee
Date of death
2015-03-26
Finding date
2020-01-31
Cause of death
Combined effects of prescribed morphine, valproic acid and midazolam leading to sedation and terminal respiratory depression due to synergistic interaction and unintended higher bioavailability of morphine
AI-generated summary
A five-year-old child with complex neurodevelopmental conditions and polypharmacy (including valproic acid for epilepsy, benzodiazepines, and other medications) underwent routine burn dressing change at hospital with oral sedation comprising morphine, midazolam, and paracetamol. The medications were administered concurrently rather than according to guidelines requiring spacing (morphine 60 minutes pre-procedure). Observations post-administration were inadequate and performed too early to assess peak drug effect or safe baseline return. The child left hospital appearing drowsy, fell asleep, and was found unresponsive hours later. Autopsy showed elevated morphine concentration suggesting impaired metabolism, likely due to the child's supratherapeutic valproic acid inhibiting hepatic glucuronidation. The synergistic effect of morphine with the child's existing sedative medications (clobazam, valproic acid, clonidine) led to respiratory depression and death. The death was potentially preventable through: specialist consultation on polypharmacy risks, adherence to sedation guidelines regarding medication timing and spacing, adequate post-sedation observations confirming return to baseline before discharge, and written discharge information about sedation side effects.
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
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Monika Chetty, aged 39, died from complications of severe acid burns covering 80% of her body sustained in early December 2013. She was found in bushland in West Hoxton on 4 January 2014 and died 27 days later at Concord…
20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…
Adam Fitzpatrick, a 20-year-old with complex facial and skull fractures from a motor vehicle collision, underwent emergency tracheostomy placement. On 22 August 2020, 13 days later, his tracheostomy tube became dislodged…
51y · Male·Pulmonary thromboemboli due to deep vein thrombosis on a background of a leg bur…
Stephen Kline, a 51-year-old Aboriginal man, died from pulmonary thromboembolism due to deep vein thrombosis following a leg burn wound sustained when NSW Police deployed a taser during a confrontation on 8 March 2016. H…
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