Deceased
Ian John Gilbert
Demographics
77y, male
Coroner
Coroner Rosemary Carlin
Date of death
2015-02-13
Finding date
2018-06-14
Cause of death
Complications of methotrexate toxicity in a man with chronic renal impairment, chronic obstructive pulmonary disease, cardiomegaly and ischaemic heart disease
AI-generated summary
A 77-year-old man with chronic kidney disease, COPD, and mild cardiac failure died from methotrexate toxicity after a GP prescribed it at an inappropriate daily dose (5mg daily) for psoriasis without baseline blood tests. The dispensing pharmacist recognized the dangerous dose, called the doctor, but ultimately dispensed the medication despite her severe concerns. Within days the patient developed toxicity symptoms, was hospitalized, and died of multiorgan failure. The coroner found the death entirely preventable. Critical failures included: the GP's failure to recognize contraindications (impaired renal function), failure to perform baseline testing despite knowing it was standard, inadequate drug reference review (only glanced at MIMS), and failure to heed the pharmacist's explicit warning. The pharmacist, despite 35 years' experience and clear safety concerns, felt constrained by perceived power imbalance with the doctor. Key lesson: methotrexate initiation requires specialist evaluation and baseline bloods; pharmacists must be empowered to refuse dispensing when safety concerns are unaddressed; and stronger safeguards are needed around dangerous drugs.
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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