Deceased
Ellen Mary O'Connor
Demographics
90y, female
Coroner
Deputy State Coroner Paresa Spanos
Date of death
2008-05-13
Finding date
2012-02-22
Cause of death
Renal failure secondary to gentamicin therapy for urinary tract infection (sepsis), with indirect contribution from renal artery stenosis and coronary artery disease
AI-generated summary
Ellen O'Connor, a 90-year-old woman with renal artery stenosis and coronary artery disease, died from acute renal failure following gentamicin administration for Pseudomonas aeruginosa urinary tract infection. A single 240mg IV dose was prescribed by a second-year resident in plastic surgery covering orthopaedics after-hours, based on an estimated weight of 45kg. The appropriate dose should have been 80-120mg; autopsy revealed she weighed only 35kg, making the dose even more excessive. No gentamicin dosing calculator was consulted despite being available via hospital intranet since 2003. Renal function deteriorated rapidly post-operatively with creatinine peaking at 440mmol/L. Critical lessons: always verify patient weight accurately, consult institutional dosing guidelines for gentamicin in elderly patients with renal impairment, and ensure after-hours cover by plastic surgery has access to senior orthopaedic advice.
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
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