Deceased
Annette Lee Douglass
Demographics
60y, female
Date of death
2018-10-14
Finding date
2020-06-03
Cause of death
Respiratory arrest in the setting of aspiration pneumonia; seizures associated with Alzheimer's disease and Down syndrome
AI-generated summary
A 60-year-old woman with Down syndrome, Alzheimer's dementia, and epilepsy died from respiratory arrest due to aspiration pneumonia after a seizure. A multi-day delay in anticonvulsant medication (phenytoin) occurred due to miscommunication between the aged care facility and her GP when the pharmacy could not supply the suspension form. The facility failed to convey urgency to the GP, did not communicate that doses had been missed, and the GP did not review the medication administration record during her visit. Abrupt cessation of phenytoin increased seizure risk, leading to aspiration. Key lessons: aged care staff must understand the criticality of essential medications, communicate urgently about supply issues, ensure GPs are informed of missed doses, and have clear protocols for medication unavailability.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
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