Deceased
Brian Edward Russell
Demographics
80y, male
Date of death
1998-05-28
Finding date
2000-04-12
Cause of death
bronchopneumonia complicated by morphine toxicity
AI-generated summary
An 80-year-old man with terminal liver disease died from bronchopneumonia complicated by morphine toxicity following a medication administration error. A Graseby infusion pump was incorrectly set at 99mm/hour instead of the intended 1mm/hour, delivering the entire 10-hour dose within 15 minutes. The nurse who set the pump had no prior experience with this device, did not consult the procedure manual or more experienced colleagues, and attempted correction with a paperclip rather than seeking proper assistance. After the overdose was discovered, naloxone was administered, then additional morphine was given despite ongoing signs of distress. The case highlights critical failures in equipment training, procedural compliance, and post-incident management, with nursing staff removing evidence before coronial investigation could occur. Proper training, equipment maintenance, procedure standardisation, and incident response protocols would have prevented this death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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