Inquest into the Death of Taylor, Evelyn
Deceased
Evelyn Taylor
Demographics
87y, female
Date of death
2010-12-02
Finding date
2013-09-11
Cause of death
heart failure and probable pneumonia in an elderly lady complicated by morphine toxicity
AI-generated summary
An 87-year-old woman with dementia, heart disease, and hypertension presented with chest pain and hypoxia. A locum doctor (Dr B.) administered 20mg morphine intramuscularly without reviewing the patient's notes, medical history, or full clinical picture. The deceased was opioid-naïve, frail, and at high risk from respiratory depression. The morphine caused toxicity with respiratory depression and was potentially lethal. However, the coroner found insufficient evidence that morphine alone caused death, given multiple comorbidities and the fact the patient survived several days with hospital treatment. Key clinical lessons: always review past medical history and medication charts, avoid high-dose opioids in elderly opioid-naïve patients with respiratory failure, consider alternative analgesia, stay to monitor after morphine administration, and verify medication expiry dates.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- inappropriately high dose of morphine (20mg) administered to opioid-naïve elderly frail patient
- failure to review patient's medical history and medication charts
- failure to consider patient's age, frailty, dementia, and lack of prior opioid exposure when determining dose
- administration of expired morphine (expiry April 2009)
- intramuscular rather than intravenous route
- failure to remain at bedside to monitor patient after morphine administration
- pre-existing heart disease and pulmonary oedema
- respiratory failure and hypoxia prior to morphine administration
- patient's overall frailty and comorbidities
- locum doctor's time pressure and overwork (70 hours per week)
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