Finding into death of Maria Dolores Coliero

Contributing factors

• cerebrovascular disease
• diabetes mellitus
• coronary artery atherosclerosis
• aspiration pneumonia
• emphysema
• base of skull osteomyelitis
• use of non-luer lock syringe for oral medication
• failure to use appropriate amber oral dispenser
• transfer of medication between syringes without awareness of route error
• lack of immediate recognition of medication administration error

Coroner's recommendations

1. Mandatory use of amber oral/nasogastric dispensers for all enteral feeding tube medications
2. Nursing staff must complete PICC line e-learning packages before accessing PICC lines
3. Medical staff must prescribe medications with clear route specifications and avoid combinations of per oral/intravenous orders
4. Medical staff altering medication orders must sign or initial changes for identification
5. When an iatrogenic event is known or suspected, a code blue should be called despite existing NFR orders to allow medical assessment of reversibility
6. Ongoing education for medical staff on appropriate prescribing of drug routes
7. Importance of thorough communication with families about NFR orders and their implications, with clear documentation of family understanding
8. Regular review and documentation of NFR orders during hospital admissions