Finding into death of Gayle Patricia Carley
Deceased
Gayle Patricia Carley
Demographics
77y, female
Date of death
2023-10-19
Finding date
2026-08-20
Cause of death
Ischaemic heart disease
AI-generated summary
Gayle Patricia Carley, 77, collapsed unwitnessed at home with acute ischaemic heart disease on 19 October 2023. Ambulance paramedics arrived and initiated emergency treatment, but a MICA paramedic inadvertently administered metaraminol at 10 times the prescribed dose (5mg instead of 0.5mg). The error occurred because the paramedic misremembered the new vial concentration (thought 1mg/1ml vs actual 10mg/1ml), was under time pressure, and worked without peer verification. The patient deteriorated into pulseless electrical activity requiring CPR and intubation, but could not be resuscitated. Post-mortem toxicology confirmed metaraminol presence, but expert review found it likely did not have the intended physiological effect and did not significantly contribute to death. Coroner findings: the medication error, while preventable, did not cause or substantially contribute to the fatal outcome given the severe underlying condition. Ambulance Victoria implemented improvements including better medication labeling and continuing education reinforcement.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Paramedic administered metaraminol at 10 times prescribed dose
- Paramedic misremembered vial concentration
- Paramedic working alone without peer double-checking
- Time pressure and high cognitive load during emergency response
- Failure to review updated clinical practice guidelines
- Underlying ischaemic heart disease
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