Non-inquest findings into the death of Charlotte Paluszak

Contributing factors

• Lack of medical assessment when patient acutely deteriorated
• No physical examination by GP before commencing end-of-life care
• Inadequate pain assessment prior to high-dose opioid administration
• Overly broad anticipatory prescribing of end-of-life medications without starting dose guidance
• Administration of highest dose opioid range without clinical justification
• Inadequate documentation of clinical reasoning for medication dosing
• Cessation of diabetes monitoring without proper oversight
• Lack of follow-up contact by GP after authorizing end-of-life medications

Coroner's recommendations

1. Residential aged care facilities should strengthen safeguards when considering prescription and administration of end-of-life treatment
2. GPs should not prescribe overly broad ranges for anticipatory end-of-life medications; specific starting doses should be provided with clear titration guidance
3. GPs should communicate directly with nursing staff about the appropriate starting dose for end-of-life medications
4. GPs should arrange follow-up contact (by phone or in-person visit) to review patient comfort and medication efficacy when end-of-life care is commenced
5. Nursing staff should commence opioids at the lowest prescribed dose in opioid-naïve patients with careful titration upwards
6. Formal pain assessments should be documented prior to administering opioid medications
7. Best practice requires GP review of resident and case conference with family before commencing end-of-life care pathways (when practicable)
8. Renal impairment should be considered when prescribing opioids; morphine metabolites accumulate in patients with renal failure
9. Two-hourly monitoring of patient comfort and medication efficacy should occur for patients on end-of-life medications
10. Clear documentation of clinical reasoning must accompany decisions to administer higher doses of PRN medications