Finding into death of Elsinore Mitchell

Contributing factors

• medication error: Nitrazepam 15mg administered instead of Mirtazapine 15mg
• drug name similarity (Nitrazepam/Mirtazapine)
• lack of familiarity with medications
• time pressure to transfer patient to another facility
• sedation-induced aspiration of gastric contents
• hospital-acquired pneumonia
• relative inexperience of junior nurse in medication administration

Coroner's recommendations

1. Commendation of Southern Health's remedial actions following internal review including annual medication administration assessments and Look-Alike Sound-Alike drug safety initiative
2. Implementation of electronic prescribing systems with built-in checks and balances to prevent administration of wrong drugs with similar names
3. Consideration of keeping non-imprest Schedule II drugs off wards unless required for current patients
4. Implementation of verbal confirmation protocol when two nurses check drugs from dangerous drug cupboard
5. Continued focus on medication safety in elderly and multi-comorbid patients given higher risk of serious consequences from sedation errors