Coroner's Finding: HERBERT Raelene Vicki

Contributing factors

• excessive morphine dosing (30mg twice) based on incorrect weight-based calculation rather than age-based dosing
• morphine administration in a morphine-naïve patient without appropriate tolerance
• morphine use for acute migraine contrary to guidelines (should only be last resort)
• failure to assess prior oral analgesia response before prescribing morphine
• second dose of morphine given by telephone without direct patient examination
• inadequate handover communication from Dr Kurtzer to hospital staff about morphine administration
• inadequate nursing observations post-morphine administration (no checks for 2+ hours)
• nursing communication failure between two nurses regarding monitoring duties
• door closed limiting ability to detect respiratory distress
• no documented sedation score or respiratory rate monitoring despite narcotic administration
• marked tonsillar enlargement from infectious mononucleosis creating upper airway narrowing
• additional sedating medications (Maxolon, Stemetil) increasing respiratory depression risk
• absence of guidelines for safe opioid administration at regional hospital

Coroner's recommendations

1. The Minister for Health should give consideration to how the Department might provide assistance in regular dissemination of information to Directors of Nursing in regional hospitals concerning developments relevant to patient safety and welfare to promote consistency of practice between larger hospitals and regional hospitals.
2. The Minister for Health should make necessary arrangements as soon as possible to ensure that all hospitals within the State are alerted to the Royal Adelaide Hospital guidelines for the administration of intermittent subcutaneous and intravenous opioid administration for acute pain management.