Shaw, Lillian Margaret

Contributing factors

• inadequate physical examination on all three visits
• failure to inspect or inquire about appearance of dark vomitus despite NSAID use
• failure to consider or diagnose perforated gastric ulcer
• inappropriate administration of 30mg intramuscular morphine at home without firm diagnosis
• morphine masking symptoms and signs of peritonitis and perforation
• weak advice regarding hospitalisation; did not firmly insist patient be hospitalised
• failure to arrange hospital admission despite recognising need
• failure to inform patient or relatives of morphine administration
• no follow-up arrangements or monitoring after final visit
• incomplete medical records; final visit and morphine injection not documented
• lack of adequate supervision of doctor with conditional registration
• long-term NSAID use without gastroprotection for known risk factors

Coroner's recommendations

1. Implement a register for controlled drugs (pethidine and morphine) that records not only removal from storage but also the actual amount administered to the patient and what became of any unused portion.
2. Establish detailed protocols specifying the level of supervision required for medical practitioners registered under Section 135 of the Medical Practitioners Registration Act 2001 (those with qualifications from non-accredited institutions), with systems to monitor and verify that supervision is actually being provided, including periodic performance reviews.
3. Implement a protocol to ensure subsequent medical practitioners and hospitals are aware of recent treatment and drugs administered by previous practitioners, particularly where the initial practitioner recognises the patient is unwell and likely to be admitted to hospital soon. This should include verbal information to the patient and/or written documentation provided to the patient to hand to the hospital.
4. Require medical practitioners registered under Section 135 to inform patients of their conditional registration status so patients can make an informed choice about their care.