Johnston, Margaret Allan

Contributing factors

• Exogenous insulin administration (two doses)
• Severe hypoglycaemia
• Cerebral strokes
• Inadequate insulin access controls
• Loose swipe card access management
• Medication prepared in advance of administration
• Poor medication documentation practices
• Inadequate observation recording by nursing staff

Coroner's recommendations

1. Clarify the intent behind the amendment to the hospital's Medication – Prescribing, Dispensing, Checking, Administration, Documentation and Storage policy (clause 4.5.2) to make clearer that it is not best practice to prepare or check medications in advance of administration
2. Adopt a policy requiring that any adverse event identified as constituting a blameworthy act (intentional unsafe act, deliberate patient abuse, or conduct constituting a criminal act) that may result in death or permanent injury be reported immediately to a senior person (such as Director of Medical Services), who must then immediately report the incident to police if the criteria are met
3. Ensure adequate auditing of medication room policies for compliance and that staff understand the intent behind such policies
4. Develop clearer national guidance on when police should be notified in suspected criminal incidents within healthcare settings