Deceased
Veronica Lesley Roberts
Demographics
75y, female
Coroner
Coroner Audrey Jamieson
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. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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Source and disclaimer
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