Coroner's Finding: WERNER Cynthia Joy
Deceased
Cynthia Joy Werner
Demographics
76y, female
Date of death
2010-12-19
Finding date
2014-04-17
Cause of death
colchicine toxicity
AI-generated summary
A 76-year-old woman with gout died from colchicine toxicity after being prescribed 500µg three times daily on 9 December 2010 for an acute attack. She developed diarrhoea from 15 December and died on 19 December with a potentially lethal blood colchicine level of 0.025mg/L. The coroner found no criticism of the treating GP or nursing home. However, the case highlights that colchicine's serious toxicity risk—including multi-organ failure—is not widely known in the medical community. Expert evidence showed prednisolone is preferred for acute gout. Discrepancies exist between MIMS and the Australian Medicine Handbook regarding colchicine dosing. The coroner recommended informing the medical community about colchicine toxicity risks and dosage ambiguities in published guidelines.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- excessive colchicine dosing (500µg three times daily)
- inadequate understanding of colchicine toxicity risks among medical community
- failure to cease colchicine promptly when diarrhoea developed despite it being a known side effect
- electrolyte derangements (low potassium, acidosis) from diarrhoea secondary to colchicine
- discrepancies between MIMS and Australian Medicine Handbook regarding colchicine dosing recommendations
- lack of monitoring for colchicine toxicity despite known gastrointestinal side effects
Coroner's recommendations
- The Minister for Health take appropriate steps to draw to the attention of the medical community the issues identified in this finding with respect to the potential for toxicity in the use of colchicine and the fact that there appear to be discrepancies in some of the publications related to dosage.
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