Finding into death of Heather Jean Lucas

Contributing factors

• rechallenge with carboplatin despite prior hypersensitivity reaction
• lack of medical presence in Day Oncology Unit at bedside during drug administration
• absence of first-line anaphylaxis treatment (epinephrine) immediately available and administered
• inaccurate adverse drug reaction documentation in Patient Assessment Tool
• use of non-first-line medications (hydrocortisone and promethazine) rather than epinephrine as initial treatment
• absence of recognised grading scale for hypersensitivity reactions
• inadequate informed consent documentation regarding rechallenge risks

Coroner's recommendations

1. Cabrini Health review the grading scale utilised in the Platinum Hypersensitivity Reaction Guideline and consider implementing a recognised scale with detailed signs and symptoms for each grade to reduce possibility of underestimation of severity
2. Cabrini Health review procedures to ensure an appropriately qualified, trained and equipped medical practitioner is at the bedside during administration of chemotherapy agents in patients undergoing rechallenge, at least for administration and for a period within which adverse reactions would manifest, and that patients with Grade 2 or greater prior reactions will not be rechallenged
3. Cabrini Health review record keeping processes and procedures including the Adverse Drug Reaction System to ensure all adverse drug reactions are recorded timely on all databases and are explicitly considered before any rechallenge
4. Patient Assessment Tool – Day Oncology be amended to allow explicit recording of allergic reactions to reduce reliance on patient recall
5. Cabrini Health implement these processes and procedures across all its campuses