Deceased
Sotirios Temopoulos
Demographics
76y, male
Coroner
Coroner Simon McGregor
Date of death
2020-08-16
Finding date
2022-11-03
Cause of death
Chest sepsis in a man with ischaemic heart disease
AI-generated summary
A 76-year-old man with multiple myeloma and complex medical history died from chest sepsis and myocardial infarction following a medication dispensing error. After discharge from hospital for spinal compression fractures, a pharmacy error resulted in three medications prescribed to another patient being delivered in his medication bag. The patient and family were unaware of the error. He presented with nausea, vomiting, and decreased oral intake several days later and deteriorated rapidly with pneumonia, acute kidney injury, and sepsis. Clinical lessons include: ensure medication lists are provided at discharge even for minor changes, particularly when family cannot attend ward visits; implement robust final checks between medication labels and delivery bags; improve communication during transitions of care; and recognize that COVID-19 restrictions limiting family presence may compromise discharge education. Early recognition of deterioration and escalation after discharge might have altered outcomes.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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