Deceased
Caroline Anne McCormack
Demographics
74y, female
Coroner
Coroner Audrey Jamieson
Date of death
2021-03-22
Finding date
2025-03-03
Cause of death
Infective exacerbation of chronic obstructive airways disease in the setting of a medication administration error (pregabalin)
AI-generated summary
Caroline McCormack, 74, died from infective exacerbation of chronic obstructive airways disease following a medication administration error where pregabalin was erroneously included in her Webster-pak despite being ceased by palliative care. She experienced a fall due to drowsiness from the medication on 17 March, was admitted to hospital on 19 March with declining consciousness, and died 22 March. The coroner found the error resulted from systemic pharmacy failures: multiple prescribers using different communication methods (phone, fax, personal visit) and failure to update electronic records when manual changes were made. The error occurred in an error-prone environment with complex medication management. While pregabalin may have increased aspiration risk, causation to death could not be definitively established. The coroner recommended hospital discharge medication lists be sent directly to community pharmacies.
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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