Coroner's Finding: Kelly, Brian John
Deceased
Brian John Kelly
Demographics
71y, male
Date of death
2020-01-04
Finding date
2020-11-26
Cause of death
hydromorphone toxicity
AI-generated summary
71-year-old man with end-stage mesothelioma died from hydromorphone toxicity after receiving 20mg instead of the prescribed 2mg dose in the ED. The overdose was accidental but resulted from shocking inattention to basic medication safety principles. The death was initially certified as due to metastatic mesothelioma rather than being reported to the coroner. Key clinical lessons include the critical importance of dose verification in palliative care settings, proper death reporting obligations, and implementation of robust medication safety checks. The coroner emphasised that acceptable standards of care were not met and recommended implementation of the hospital's RCA recommendations to prevent recurrence.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- medication error - tenfold overdose of hydromorphone
- lack of attention to basic medication safety principles
- failure to verify prescribed dose before administration
- failure to report death to coroner
Coroner's recommendations
- Immediate steps should be taken by the Hospital to ensure an accident of this type cannot happen again
- Implementation of the recommendations contained in the Tasmanian Health Service RCA Final Report
Full text
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