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ES, a 87 year old lady

Deceased

Demographics

87y, female

Coroner

Lock

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. Report an inaccuracy.

Specialties

general practicepalliative carecardiologynephrology

Error types

medicationcommunicationsystemdelay

Drugs involved

morphinefentanyloxycodonewarfarinmetoprolol

Clinical conditions

congestive cardiac failureischaemic heart diseasechronic kidney diseaseemphysemaatrial fibrillationcoronary atherosclerosisischaemic cardiomyopathyopioid toxicitymixed drug toxicity

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

Full text

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Source and disclaimer

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