Finding into death of Alan Gordon Wolstenholme
Deceased
Alan Gordon Wolstenholme
Demographics
72y, male
Date of death
2024-07-29
Finding date
2026-07-27
Cause of death
Complications of suspected upper gastrointestinal tract haemorrhage, hospital acquired pneumonia/aspiration pneumonia and renal impairment in a man with multiple comorbidities following the administration of multiple opioids
AI-generated summary
A 72-year-old man with metastatic squamous cell lung cancer and multiple serious comorbidities was admitted to Ballarat Hospital in July 2024 with lethargy, fatigue, and rapid atrial fibrillation. Due to medication charting errors on admission, he was prescribed multiple opioid medications (buprenorphine patch, oxycodone extended-release, pregabalin) he was not usually taking. He refused these medications in the Emergency Department, explicitly noting they were not his regular medications, but this refusal was not escalated to the prescriber. Three days later, he was found unresponsive from opioid overdose and required naloxone reversal. Despite ICU treatment, he subsequently developed upper gastrointestinal bleeding, acute kidney injury, hospital-acquired pneumonia, and died. The coroner found the medication error was preventable but did not cause his death, which resulted from natural disease processes. Key systemic failures included inadequate Best Possible Medication History completion on admission, insufficient pharmacy staffing outside business hours, and lack of protocols for escalating medication refusals.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Multiple incorrect medications prescribed and charted on admission
- Best Possible Medication History (BPMH) not completed prior to medication charting
- Medication chart completed by multiple clinicians without proper verification
- Inadequate pharmacy staffing outside business hours
- Patient refusal of medications not escalated or reviewed by prescriber
- Inadequate protocols for managing and escalating medication refusals
- Opioid toxicity from excessive opioid dosing in opioid-naive patient
- Multiple serious comorbidities including metastatic cancer and atrial fibrillation
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