Inquest into the death of Diane EASTCOTT
Deceased
Diane Eastcott
Demographics
71y, female
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.
Error types
Contributing factors
- inadvertent concurrent prescription of metoprolol and verapamil
- failure to identify contraindicated medication combination despite pharmacist alert
- absence of documented discussion between pharmacist and medical team regarding drug interaction
- failure to reconcile medications upon hospital discharge
- discharge summary not received by general practitioner
- lack of follow-up with general practitioner after discharge
Coroner's recommendations
- A review should be conducted of the circumstances relating to the re-admission of Diane Eastcott to Macquarie Hospital following her discharge from Ryde Hospital on 28 June 2018 in circumstances where Diane's discharge summary from Ryde Hospital was not sent to, or not received by, Diane's usual general practitioner, in order to ensure that appropriate mechanisms exist to allow for a discharge summary to be received by a discharged patient's general practitioner as intended.
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