Finding into death of AH
Deceased
AH
Demographics
37y, male
Coroner
Coroner Sarah Gebert
Date of death
2017-06-26
Finding date
2021-09-21
Cause of death
Mixed Drug Toxicity (Oxycodone, Quetiapine, Pregabalin and Clonazepam)
AI-generated summary
A 37-year-old man died from mixed drug toxicity (oxycodone, quetiapine, pregabalin, clonazepam) after ingesting unknown quantities of his own medications in an ED. He presented with trauma symptoms four days post-motor vehicle accident and was observed taking Targin (oxycodone/naloxone) at 9:50am. Despite receiving naloxone doses and being in a monitored resuscitation cubicle, he deteriorated with worsening conscious state (GCS 15→11→9) and was found in cardiac arrest at 2:22pm. Critical failures included: inadequate knowledge of Targin's prolonged action and naloxone's short duration; no documented VPIC consultation despite overdose recognition; poor handover (substance recorded as "unknown" by consultant despite nursing documentation of Targin); inadequate observation with last nursing notes at 1:00pm and observations at 1:45pm showing GCS 9 with no escalation; and monitor alarm failure. The coroner found the death readily preventable with appropriate pharmacological knowledge and monitoring. Hospital implemented substantial improvements including new monitoring equipment, dedicated staff allocation for high-acuity patients, enhanced observation protocols, and educational changes.
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Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- inadequate staff knowledge of Targin pharmacology and prolonged duration of action
- inadequate knowledge of naloxone's short duration of action relative to long-acting opiates
- failure to contact Victorian Poisons Information Centre despite overdose recognition
- poor handover and communication between medical and nursing staff regarding substance ingested
- inadequate clinical observation following recognition of overdose and deteriorating conscious state
- failure of monitoring equipment alarm system to alert staff to deterioration
- monitor leads displacement not detected
- incomplete documentation of clinical findings and management decisions
- cervical collar remaining in place potentially compromising airway assessment
Coroner's recommendations
- La Trobe Regional Hospital continue to conduct ongoing education for all levels of staff regarding the management of opiate toxicity, particularly as it applies to long acting formulations
Full text
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