Non-inquest findings into the death of Jean Alice Dowson

Contributing factors

• Severe COPD with bronchiectasis
• Respiratory failure
• Severe frailty and low body weight (29kg)
• Deterioration following hospital discharge for dehydration
• Broad anticipatory prescribing of end-of-life medications without explicit starting dose guidance
• Administration of highest dose range of morphine and midazolam rather than lowest dose
• Inadequate documentation of clinical assessment and rationale for medication doses
• GP unavailable for physical review on day of deterioration
• Lack of pain assessment prior to administering highest dose medications
• Insufficient consideration of patient's low body weight and respiratory status when determining dose

Coroner's recommendations

1. Implement narrower dose ranges for anticipatory end-of-life prescriptions in aged care settings with explicit guidance on starting doses
2. Require GP review and documented clinical assessment prior to commencing end-of-life medications, including consideration of alternatives such as telephone or video conferencing when physical presence is not possible
3. Establish requirement to commence PRN medications at lowest prescribed dose unless clear documented clinical reasons exist for higher initial dose
4. Implement mandatory pain and symptom assessment documentation prior to administering end-of-life medications, with specific documentation of clinical reasoning for dose selection
5. Ensure explicit consideration and documentation of patient factors such as body weight, renal function, respiratory status, and opioid tolerance when determining end-of-life medication doses
6. Develop clear protocols for communication with families regarding intent to commence end-of-life care and obtain informed consent
7. Ensure completion of end-of-life assessment forms and care plans prior to commencing end-of-life medications
8. Provide regular training and support to clinical staff on appropriate end-of-life care practices and documentation standards
9. Implement regular auditing of end-of-life medication prescribing and administration to ensure compliance with guidelines