ES, a 87 year old lady
Deceased
ES
Demographics
87y, female
Date of death
2014-07-16
Finding date
2017-02-07
Cause of death
Multiple opioid drug toxicity (morphine and fentanyl) in combination with congestive cardiac failure and emphysema; underlying coronary atherosclerosis, ischaemic cardiomyopathy, and chronic kidney disease
AI-generated summary
An 87-year-old woman with multiple comorbidities (ischaemic heart disease, emphysema, chronic kidney disease) was discharged home for palliative care after a hospital admission. Her family administered excessive doses of oral morphine and misapplied fentanyl patches that had been returned to them from a nursing home. Clinical lessons: (1) Discharge planning must include written medication guidance and family education on when to seek medical review; (2) Specialist palliative care input should be established before discharge when anticipated; (3) Ceased medications should not be returned to families without clear documentation; (4) When symptoms worsen at home, medical assessment should occur rather than escalating medications without advice; (5) Clear labelling of opioid dosing instructions (specifically stating hours between doses) is essential to prevent misadministration.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Excessive administration of oral morphine by family members
- Misapplication of fentanyl patches at twice the prescribed rate
- Fentanyl patches not appropriately removed when new patches applied
- Family unaware GP had ceased fentanyl patches prior to discharge
- Nursing home returned ceased medications to family without clear documentation
- Lack of written medication plan or family education on administration and signs of deterioration
- Rushed discharge process without specialist palliative care involvement
- No medical assessment when patient deteriorated within days of discharge
- Family escalated medication doses without medical advice in response to patient distress
- Enrolled nurse administered excessive morphine dose without medical consultation
- Unclear dosing instructions on medication labelling leading to misunderstanding of frequency
- Lack of access to timely medical review or after-hours assessment
Coroner's recommendations
- The Therapeutic Goods Administration should consider requiring prescribers or manufacturers of Ordine and all other strong narcotic medications to state dosage specifically in the number of hours between taking the next dose and place clear warnings on insert material and packets that failure to follow instructions strictly may have serious consequences including death
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