Finding into death of S M

Contributing factors

• Prescriber failed to verify drug allergy despite documented contraindication
• Reliance on patient's verbal confirmation of allergies despite severe dementia
• Failure to consult medical records, in-house GP, or family regarding allergies
• Dispensing pharmacist dismissed allergy alerts as 'not relevant' based on prior similar medication
• Second pharmacist failed to identify contraindicated medication during sign-off
• Pharmacy software did not prevent dispensing of contraindicated medication
• Nursing staff did not verify allergies before administration
• Lack of communication between prescriber and in-house GP regarding medication changes
• Absence of generic drug name on medication packette label
• Failure to escalate anaphylactic reaction early to senior clinician

Coroner's recommendations

1. GM Pharmacy's Fred system should include acknowledgement and sign-off alerts for contraindicated medications
2. MPS should alter its process to prevent packaging of medications when the system indicates a contraindication
3. All medication chart labels should indicate generic names when brand names are displayed
4. Every packette should be labelled with the generic name of medications
5. Pharmacy software systems must be enhanced to ensure allergy alerts cannot be easily dismissed
6. Best Dose feature should be implemented to highlight allergies when contraindicated medications are entered
7. Prescribers should never rely on elderly patients with cognitive impairment to recall their drug allergies without verification against documentation
8. Prescribers must communicate significant medication changes to supervising GPs and nursing staff immediately
9. Enhanced training on medication safety and allergy verification for all healthcare professionals involved in aged care
10. Formal implementation of double-check procedures at dispensing and administration stages, particularly for contraindicated medications