Coroner's Finding: GREEN Marie

Contributing factors

• delayed and unpredictable morphine absorption due to underlying scleroderma and oesophageal dysmotility
• administration of metoclopramide (Maxalon) which accelerated gastric motility and increased morphine absorption
• failure to document Dr P.'s observation that patient was unfit for psychiatric assessment in clinical record until day later
• inadequate frequency of neurological observations (six-hourly only) after admission to medical ward
• lack of explicit plan documented for neurological monitoring and specific warning signs to look for
• failure to appreciate emerging signs of sedation and deteriorating consciousness on evening of admission
• inappropriate ward placement; patient should have been in high dependency unit or remained in emergency department
• lack of specialist toxicology/emergency medicine input at early stage
• failure to administer naloxone when consciousness deteriorated at 8pm

Coroner's recommendations

1. Director of Clinical Systems should draw these issues to the attention of the College of Emergency Medicine to develop a protocol for treatment of overdoses of slow-release opiates
2. Protocol should make clear that effects of slow-release medication can be highly unpredictable, particularly in patients with complex comorbidities, and that expert input is required at early stage of presentation
3. Particular consideration should be given to most appropriate hospital placement for such patients
4. Director of Clinical Systems should consider desirability and feasibility of establishing dedicated toxicology ward in tertiary public hospitals in South Australia for treatment of drug overdose patients