Coronial
SAaged care

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. Report an inaccuracy.

Specialties

general practicegeriatric medicinerheumatologyorthopaedic surgerygeneral medicine

Error types

medicationsystem

Drugs involved

colchicineallopurinolprednisoloneibuprofen

Clinical conditions

goutcolchicine toxicitymulti-organ failureacute renal failureacute liver failurerespiratory failurecardiac failurediarrhoeahypokalaemiaacidosiscardiac arrhythmiamitotic arrest

Procedures

joint aspiration

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

  1. 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.
Full text

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