Coronial
VIChospital

Finding into death of Margaret Ann Yeomans

Deceased

Margaret Ann Yeomans

Demographics

79y, female

Date of death

2016-08-09

Finding date

2018-02-19

Cause of death

Rhabdomyolysis in a woman with multiple myeloma and renal impairment

AI-generated summary

Margaret Ann Yeomans, aged 79, died from rhabdomyolysis in the context of multiple myeloma and chronic renal impairment. A critical medication error occurred when rosuvastatin 40mg was dispensed instead of her prescribed simvastatin 40mg on 27 June 2016. The pharmacist's final check failed to identify the error, and when the patient's husband raised concerns about the different medication appearance, staff reassurance prevented correction. Mrs Yeomans consumed the incorrect high-dose statin for weeks before hospital admission with acute renal failure. The coroner found the dispensing error and pharmacist's failed verification were contributing factors to her death. Clinical lessons include: rosuvastatin carries higher myopathy risk than simvastatin at high doses in elderly patients with renal impairment; pharmacy verification systems must not be bypassed by reassurance without proper checking; and patient/family concerns about medication appearance should trigger immediate pharmacist review rather than dismissal.

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

Contributing factors

  • Dispensing of incorrect statin (rosuvastatin instead of simvastatin) at high dose
  • Pharmacist's failure to verify medication during final check
  • Staff reassurance without proper verification when patient's husband raised concerns about medication appearance
  • Pre-existing chronic renal impairment
  • Pre-existing multiple myeloma
  • Advanced age
  • Controlled hypothyroidism
  • Respiratory compromise secondary to fluid overload
  • Urinary tract infection acquired in hospital

Coroner's recommendations

  1. The Epping Plaza Chemmart should institute a policy whereby concerns about dispensed medication raised by customers are referred to the pharmacist for review
  2. The National Council of the Pharmacy Guild of Australia should review the circumstances of Mrs Yeomans' death for purposes of education, awareness and creation of robust dispensing policies and guidelines
Full text

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