Coroner's Finding: PENN Dulcie Janet Mary

AI-generated summary

An 83-year-old woman with Down syndrome and cardiac disease died from congestive cardiac failure at Royal Adelaide Hospital following accidental medication administration error in a community group home. On 1 July 2007, she received her housemate's psychiatric medications (including clozapine, risperidone, valproate, and lamotrigine) instead of her own cardiac medications including digoxin. She did not receive her own medications that morning. She developed severe hypotension (systolic BP 87) and altered consciousness in emergency department within hours, requiring intubation and ICU admission. She deteriorated over three days and died on 3 July. The coroner found the wrong medication triggered her decline, with contributing factors including missed cardiac medication and underlying heart disease. Medication administration involved blister packs clearly labeled with resident names and required cross-checking procedures. The support worker failed to verify the medication name on the blister pack or cross-check the medication list despite having the correct resident's medication folder. This was a systemic failure to follow established safety checks rather than a communication issue.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.