Deceased
Diane Eastcott
Demographics
71y, female
Coroner
Decision ofDeputy State Coroner Lee
Date of death
2018-07-10
Finding date
2022-05-06
Cause of death
ischaemic cardiovascular disease
AI-generated summary
Diane Eastcott, a 71-year-old involuntary mental health patient, died of ischaemic cardiovascular disease on 10 July 2018 at Macquarie Hospital. Following an unwitnessed fall on 22 June 2018, she was admitted to Ryde Hospital where atrial fibrillation was diagnosed. A critical medication error occurred: verapamil (continued from previous prescription) and metoprolol were prescribed concurrently without clinical indication—a contraindicated combination potentially causing severe heart block. A pharmacist flagged this in a comment but no action was taken. The error was not identified despite electronic alerts and continued through her discharge and return to Macquarie Hospital. While the concurrent medications were not clinically indicated and their safety profile was concerning, postmortem examination revealed significant coronary artery disease was the probable primary cause of death. Key lessons: medication reconciliation must actively identify and prevent contraindicated combinations; pharmacist alerts require documented follow-up; discharge summaries must reliably reach general practitioners to enable appropriate follow-up care.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
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