Finding into death of Glen David Kingsun

Contributing factors

• Verapamil toxicity - likely overdose (prescribed 420mg daily, toxic level detected)
• Dangerous drug interaction between verapamil and propranolol (beta-blocker) - additive cardiac depressant effects
• Hyperkalaemia (serum potassium 7.8mmol/L) - likely from concurrent use of irbesartan, NSAIDs (Arthrexin), and thiazide diuretic causing renal impairment
• Poor coordination of care between multiple prescribers
• Medication documentation errors and confusion regarding prescribed medications and doses
• Dr B. prescribed diltiazem 320mg based on misunderstanding
• Dr N. increased verapamil to 420mg based on misinterpretation of Dr B.' intention
• Patient self-amended medication doses
• Failure of Emergency Department staff to recognise severity of condition on second presentation
• Failure to recognise ECG changes (left bundle branch block) as life-threatening hyperkalaemia
• Delayed triage (Category 4 instead of Category 2)
• Delayed treatment of hyperkalaemia

Coroner's recommendations

1. The Victoria Faculty of the Royal Australian College of General Practitioners, the Australian Medical Association Victoria, the Victorian Branch of the Pharmaceutical Society of Australia and the Victorian Branch of the Pharmacy Guild of Australia should meet to discuss the feasibility of collaborating to develop and implement a real-time prescription monitoring system to enhance members' ability to provide appropriate care to patients and reduce harms and deaths associated with poor coordination of care