Coronial
SAhospital

Coroner's Finding: PAULEY Cynthia Joy

Deceased

Cynthia Joy Pauley

Demographics

72y, female

Date of death

2010-09-20

Finding date

2013-03-08

Cause of death

Intrathecal toxicity of bupivacaine and morphine

AI-generated summary

A 72-year-old woman with terminal metastatic parotid cancer died from intrathecal toxicity of bupivacaine and morphine. She was admitted to Ashford Hospital for pain management of pathological pelvic fractures. An intrathecal catheter was correctly inserted but on 20 September 2010, a senior palliative care physician ordered a bolus dose of 5mg morphine and 3ml bupivacaine, intending epidural administration but the line was intrathecal. These doses were excessive for intrathecal delivery. The patient collapsed within 35 minutes, with profound hypotension (56/32) and respiratory depression. She received naloxone, briefly improved, then deteriorated again and died 4 hours later. The coroner found no alternative anatomical cause. Clinical lessons: verify catheter type before administration, implement enhanced monitoring after intrathecal bolus dosing, clarify resuscitation plans early in dying patients, and involve family in resuscitation decisions when acute medical events occur.

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

Specialties

palliative careoncologypain medicineanaesthesia

Error types

medicationproceduralcommunicationsystem

Drugs involved

morphinebupivacainenaloxonehydromorphonefentanylamitriptylinemidazolam

Clinical conditions

metastatic parotid acinic carcinomametastatic cancer to brain, lungs, liver, skeletonpathological pelvic fracturesrespiratory depressionhypotensionopioid toxicity

Procedures

intrathecal catheter insertionintrathecal bolus medication administration

Contributing factors

  • Incorrect identification of catheter type (intrathecal misidentified as epidural)
  • Excessive bolus dose prescribed for intrathecal administration
  • Inadequate monitoring following intrathecal bolus administration
  • Failure to establish formal resuscitation status documentation prior to incident
  • Lack of consultation with family regarding resuscitation measures

Coroner's recommendations

  1. The General Manager of Ashford Hospital should draw to the attention of all clinical staff the need to closely monitor vital signs of patients to whom intrathecal bolus analgesia has been administered
  2. Implementation of clearer documentation and discussion of resuscitation status for dying patients prior to acute events
  3. Where collapse of a dying patient occurs due to medical misadventure, consultation with family members should occur regarding extent of resuscitative measures to be applied
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