Finding into death of Julie Stephens
Deceased
JULIE ANNETTE STEPHENS
Demographics
54y, female
Date of death
2008-12-19
Finding date
2008-03-20
Cause of death
sepsis
AI-generated summary
Ms Julie Stephens, aged 54, was admitted to Frankston Hospital on 5 December 2008 with a chest infection and multiple comorbidities including cardiac failure, respiratory failure, and obesity. She deteriorated with septic shock secondary to pneumonia and was transferred to ICU where she was intubated and given morphine sedation despite documented morphine allergy—a significant oversight not identified until 11 December. She developed ARDS, acute renal failure, and abdominal sepsis, ultimately dying from sepsis on 19 December. Post-mortem examination found no evidence of anaphylaxis from morphine exposure. The coroner found hospital management within reasonable parameters but criticised the failure to identify and prominently display the allergy before medication administration, recommending allergy stickers on medical record covers.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- community-acquired pneumonia
- reduced cardiac and respiratory reserve
- congestive cardiac failure
- chronic obstructive pulmonary disease
- morbid obesity
- acute respiratory distress syndrome
- acute renal failure
- possible abdominal sepsis
- morphine administered despite documented allergy
Coroner's recommendations
- That Frankston Hospital considers placing an allergy warning sticker on the front cover of medical records for all patients with known drug and food allergies
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