Deceased
Frank Maurice Whittington
Demographics
66y, male
Coroner
Tonkin
Date of death
2004-02-24
Finding date
2007-12-12
Cause of death
Coronary atherosclerosis
AI-generated summary
Frank Maurice Whittington, aged 66, died from coronary atherosclerosis on 24 February 2004, shortly after day surgery to replace a catheter on his intrathecal morphine pump. Dr Rossato and RN Couper administered a 0.26ml overdose of morphine during post-operative pump priming due to reliance on Medtronic's calculation worksheet, which failed to account for fluid already present in the pump's internal tubing in previously-primed devices. While the overdose was established, the coroner found it did not contribute to death in this highly morphine-tolerant patient. The underlying coronary artery disease and a massive meal consumed post-operatively triggered the fatal heart attack. Key clinical lessons: manufacturers must provide clear, context-specific guidance for device programming; clinicians should verify calculations independently; and pre-existing cardiac disease may remain asymptomatic despite severe pathology, particularly in pain patients receiving excellent analgesia from intrathecal delivery.
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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