Coronial
VICaged care

Finding into death of Veronica Lesley Roberts

Deceased

Veronica Lesley Roberts

Demographics

75y, female

Date of death

2020-10-05

Finding date

2025-05-22

Cause of death

Ischaemic heart disease in the setting of unstable type 2 diabetes mellitus and a recent insulin administration error

AI-generated summary

Veronica Roberts, 75, died from ischaemic heart disease complicated by unstable diabetes and a medication error. On 4 October 2020, her insulin dose was increased to 20 units daily, but due to Electronic Medical Record (Cerner) system failures, she received a second 20-unit dose the same afternoon in addition to her morning 15-unit dose. The prescriber failed to refresh the system to verify the new dose date, and nursing staff did not identify the duplicate dose despite an electronic alert being overridden. Contributing factors included system design flaws, alarm fatigue, and staff knowledge gaps. While the coroner could not definitively prove the medication error caused death, she found the EMR system contributed significantly. Key lessons: EMR systems require user-centred design, mandatory verification steps for high-risk medications, and standardised approaches across health services. Alert fatigue remains a persistent safety concern.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

geriatric medicinegeneral medicineintensive carecardiology

Error types

medicationsystem

Drugs involved

glargine insulinthickened cordial

Clinical conditions

ischaemic heart diseaseacute myocardial infarction (nstemi)type 2 diabetes mellitushyperglycaemic hyperosmolar statesystolic heart failureperipheral vascular diseaseiron deficiency anaemiachronic kidney diseaseacute kidney injuryurinary tract infectiondeliriumhypoglycaemia

Contributing factors

  • Medication administration error - duplicate insulin dose
  • Electronic Medical Record (Cerner) system design flaws
  • Failure to refresh EMR screen to verify dose date/time
  • Nursing staff failure to identify duplicate dose despite electronic alert
  • Override of Early Medication Warning alert
  • Alarm fatigue
  • Lack of standardised medication management procedures
  • Staff knowledge/skills gaps regarding EMR system
  • Patient's unstable diabetes mellitus
  • Patient's complex medical history

Coroner's recommendations

  1. Oracle Health (Cerner vendor) should progress the idea logged by Peninsula Health on 6 May 2021 for the system to warn clinicians if the first dose date/time of a new medication order lands within the minimum interval of the last time the same medication was administered, with report on feasibility and timelines
  2. Peninsula Health should review the Electronic Medication Management – Prescribing High-Risk Medicine Guidance and eHealth High Risk Medicine Safety – Rapid Literature Review and Environmental Scan report and consider whether any further measures can be implemented to reduce high-risk medication errors
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