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. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
73y · Female·fractured neck of femur (operated) on a background of Alzheimer's dementia
Linda Eileen Saberton, aged 73, died from complications of a fractured neck of femur sustained in a fall at her aged care facility, on a background of advanced Alzheimer's dementia. She had suffered two hip fractures wit…
79y · Female·multi-organ failure as a result of ischaemic and valvular heart disease with uri…
Janet Ann Cook, aged 79, died of multi-organ failure complicated by hydromorphone toxicity on 30 September 2015. She was mistakenly administered 16mg hydromorphone intended for another patient (room 28 vs room 26) on 21 …
80y · Male·bronchopneumonia complicated by morphine toxicity
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 …
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