Inquest into the Death of Antoinette WILLIAMS

Contributing factors

• medication error in haloperidol preparation and administration
• failure to communicate medication error to receiving teams
• misinterpretation of haloperidol dosage documentation
• lack of ECG monitoring despite high-dose antipsychotic exposure
• inadequate respiratory monitoring at Graylands
• underlying undiagnosed myocarditis
• multiple sedating drugs administered in Broome Hospital
• poor handover procedures between transport and receiving hospital

Coroner's recommendations

1. Obtain comprehensive summary of all drugs and doses administered before RFDS handover; review totals and seek advice if daily maximums reached
2. Limit use of drugs to recommended maxima, exceeding only with careful consideration of risks and benefits
3. Adequately monitor all patients during transport with ECG monitoring where possible and review QT interval
4. Implement cardiac monitoring if QT prolongation detected
5. Notify receiving hospital in advance if patients exceeded recommended daily maximums, ensuring full medical assessment including 12-lead ECG on arrival
6. Clearly document total doses of each drug on observation chart and discuss at handover
7. Develop revised inter-hospital transfer forms to include information specific to sedated psychiatric patients and total doses of sedative medication in last 24 hours
8. Implement requirement for RFDS drug requests to be written on hospital medical chart, signed by RFDS or hospital doctor, and prepared by authorised staff in presence of RFDS staff member
9. Increase clinical staff awareness of need for ECG monitoring for patients receiving more than 20mg haloperidol or droperidol within 24 hours
10. Update sedation policy and guidelines with training for clinical staff
11. Implement staff education in responses to critical incidents when errors occur
12. Roll out revised curriculum for clinical observation training at all mental health in-patient units
13. Establish formal procedures to ensure medication error information is passed to receiving facilities