Coroner's Finding: RUSSELL Brian Edward
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.
Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- infusion pump set incorrectly at 99mm/hour instead of 1mm/hour
- nurse unfamiliar with Graseby pump operation
- failure to consult procedure manual
- failure to seek assistance from experienced staff
- damaged pump controls with plastic screws
- pump not properly serviced or maintained
- inadequate training in specialised medical equipment
- pre-existing renal and hepatic failure impairing morphine clearance
- bronchopneumonia preceding the overdose
- inappropriate administration of naloxone followed by additional morphine
Coroner's recommendations
- Nurse Managers at Flinders Medical Centre take steps to ensure that unexpected deaths of patients are reviewed, and follow-up counselling and education is provided to nursing staff involved
- Flinders Medical Centre institute an appropriate regime for the use of specialised medical equipment such as the Graseby pump in general wards to ensure that nurses using that equipment are proficient in its use
- Flinders Medical Centre institute a regular servicing and maintenance programme for medical and scientific equipment used at the hospital, and in particular review the serviceability of the other Graseby pumps in use
- The Attorney-General consider whether an amendment to Section 26(3) of the Coroners Act is required to enable a coroner to find whether or not there has been negligence in the delivery of palliative care, having regard to the provisions of Section 17(3) of the Consent to Medical Treatment and Palliative Care Act
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