Coronial
QLDhospital

Loveday, Marcia Joy

Deceased

Marcia Joy Loveday

Demographics

74y, female

Coroner

O'Connell

Date of death

2010-07-23

Finding date

2013-10-28

Cause of death

Cardio-renal failure due to gangrene of calculous gallbladder, with significant underlying conditions of hypertensive and ischaemic heart disease, diabetes mellitus, and anaphylaxis reaction

AI-generated summary

An elderly woman with a documented penicillin allergy, wearing a MedicAlert bracelet, presented to emergency with respiratory distress and chest pain. She was administered intravenous Ampicillin without allergy verification, suffered anaphylaxis and cardiac arrest within minutes, and died four days later from multi-organ failure. The coroner found her death was caused by underlying conditions (gangrenous gallbladder, cardiac and respiratory disease) though the anaphylaxis occurred and she suffered arrest. Key failures: triage nurse did not document the penicillin allergy despite ambulance handover; patient's hospital file containing allergy information was not retrieved and delivered; the MedicAlert bracelet was not recognized as a medical device. Post-event care was appropriate. The coroner emphasized failures in allergy identification systems and medical staff education on recognizing medical alert devices.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicineintensive careanaesthesia

Error types

diagnosticmedicationsystemcommunication

Drugs involved

ampicillinpenicillinsalbutamolhydrocortisoneadrenalineglyceryl trinitrateclarithromycinroxithromycin

Clinical conditions

penicillin anaphylaxisanaphylactic shockcardiac arrestchronic obstructive pulmonary diseaserespiratory distresspneumonianon-st-elevation myocardial infarctiongangrenous gallbladdersepsismulti-organ failurecardio-renal failurehypertensive heart diseaseischaemic heart diseasediabetes mellitus

Procedures

intravenous cannula insertionendotracheal intubationcardiopulmonary resuscitationadvanced life support

Contributing factors

  • failure to verify penicillin allergy status before administering Ampicillin
  • failure to observe or recognize MedicAlert bracelet as medical identification device
  • failure of triage nurse to document penicillin allergy despite ambulance handover
  • failure to retrieve and deliver patient's existing hospital file to emergency department in timely manner
  • anaphylactic reaction to penicillin
  • cardiac arrest following anaphylaxis
  • system failures in emergency department triage area layout and alert flag communication
  • poor recognition factor of medical identification products by clinicians

Coroner's recommendations

  1. Manufacturers, retailers, and promoters of medical identification products should only make available items which: (i) distinctly place function over fashion in design; (ii) bear a distinct and readily recognised medical symbol or wording depicting medical identification product; (iii) have all identifying wording very prominent on the bracelet, in contrasting colour, and durable finish to be a standout feature
  2. Queensland Health and Queensland Ambulance Service should consult with experienced specialist doctors and prepare brief educational material to disseminate and educate medical personnel, especially those in Accident and Emergency Departments and first response ambulance officers, regarding anaphylaxis presentations
  3. Queensland Health should conduct an audit within six months of hospitals to identify if any similar 'Bundaberg Base Hospital 2010 style triage situation' exists elsewhere, and implement necessary changes if found
  4. Queensland Health and Queensland Ambulance Service should consult, investigate, and devise a policy to implement a wristband alert system for patients with significant medical conditions
Full text
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