Coronial
VIChospital

Finding into death of Nola Margaret Moxon

Deceased

Nola Margaret Moxon

Demographics

77y, female

Coroner

Coroner Peter White

Date of death

2009-02-02

Finding date

2014-09-12

Cause of death

Venlafaxine toxicity in a woman with severe renal impairment and depression

AI-generated summary

77-year-old woman admitted to psychiatric ward with severe depression and catatonic features. Despite documented severe renal impairment and dehydration on admission, no medical review occurred over the weekend prior to ECT. Critical pathology results showing deteriorating renal function (eGFR declining from 32 to 24) were not communicated to clinical staff due to failure of medical handover to weekend cover. Patient developed venlafaxine toxicity in context of severe renal impairment and went into cardiac arrest immediately prior to ECT. The coroner found the death was preventable through adequate medical review, transfer to medical ward for IV rehydration, and proper handover of clinical concerns. No pre-ECT anaesthetic assessment identified the concurrent medical illness.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatrygeriatric medicinenephrologyanaesthesia

Error types

communicationsystemdelay

Drugs involved

venlafaxine

Clinical conditions

major depressive disorder with catatonic featuresvenlafaxine toxicitysevere renal impairmentacute kidney injury secondary to dehydrationdehydrationhypernatraemia

Procedures

electroconvulsive therapy

Contributing factors

  • Failure to perform medical handover to weekend cover staff
  • Absence of medical review from Friday 30 January to Monday 2 February 2009
  • Failure to recognise and act upon deteriorating renal function
  • Inadequate fluid intake (520-1030 mls daily) despite known dehydration
  • Failure to transfer to medical ward for intravenous rehydration despite deteriorating renal function
  • No pre-ECT anaesthetic assessment of fitness to undergo procedure
  • Lack of formal communication regarding need for medical follow-up and investigations

Coroner's recommendations

  1. In all cases where ECT is scheduled at Caulfield Hospital, a duty anaesthetist should examine and review the fitness of the patient to undergo the procedure at least 24 to 72 hours prior to the scheduled commencement
  2. A checklist should be established to support the anaesthetic pre-procedure assessment
  3. The on-duty anaesthetist should examine and confirm the patient's fitness to undergo the procedure on the morning of the scheduled commencement
Full text
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