Cahill, Margaret Ann

Contributing factors

• Blurred professional boundaries between GP and patient who was also an employee and friend
• Failure to directly ask about tapentadol consumption before prescribing morphine
• Prescription of 60mg intramuscular morphine, an unusually high dose for general practice setting
• Lack of vital sign monitoring before discharge
• Discharge home into care of non-medically trained person
• Failure to recognise progressive narcotisation and coma throughout day
• Misinterpretation of snoring as normal sleep rather than sign of overdose
• Absence of direct patient assessment during follow-up telephone calls
• Drug interaction between tapentadol, morphine, diazepam and citalopram
• Patient and husband non-disclosure of tapentadol consumption

Coroner's recommendations

1. Royal Australian College of General Practitioners Queensland should establish and distribute comprehensive clinical guidelines for best practice administration of morphine in general practice settings, including post-administration care and observation protocols
2. Guidelines should be developed and distributed by peak professional bodies (RACGP, Rural Doctors Association of Queensland, Australian Medical Association Queensland, AHPRA, OHO) addressing morphine administration in general practice
3. Implementation of protocols limiting intramuscular morphine administration in general practice to evidence-based doses with clear observation and vital sign monitoring requirements