Finding into death of Phillip Harry Parker

Contributing factors

• Medication administration error - wrong resident given slow-release opioid
• Tapentadol SR administered in crushed form increasing bioavailability risk
• Patient care worker lapse in concentration during medication round
• Interruptions and distractions during medication administration
• Patient care worker on first unsupervised medication round
• Inadequate staffing ratios and skill mix at aged care facility
• Use of unqualified staff to administer Schedule 8 controlled medications
• Lack of proper identification procedures prior to medication dispensing
• Significant functional decline and comorbidities throughout 2017
• Chronic dysphagia and aspiration risk
• Chronic bronchiectasis and pulmonary fibrosis
• Malnutrition and cachexia
• Frailty and declining respiratory function

Coroner's recommendations

1. Review the use of patient care workers and personal care assistants in administering high-risk medications such as opioids (Schedule 8 drugs) in aged care facilities, given that hospitals adhere to strict dual-registered nurse protocols for such medications
2. Consider increased use of enrolled nurses and registered nurses rather than unqualified staff for medication administration in aged care facilities
3. Implement systems to minimize interruptions during medication rounds, including the use of 'do not disturb' signage or vests
4. Enhance medication administration training and competency assessment programs in aged care facilities
5. Review staffing ratios and skill mix in aged care facilities to ensure adequate oversight of medication administration
6. Develop consistent medication management practices between hospitals and aged care facilities, particularly for high-risk medications
7. Implement improved identification procedures prior to medication dispensing to prevent wrong-resident errors
8. Ensure adequate supervision of staff on their first unsupervised medication rounds