Inquest into the Death of Antoinette WILLIAMS
Deceased
Antoinette WILLIAMS
Demographics
19y, female
Date of death
2012-10-13
Finding date
- 11 April 2014
Cause of death
combined drug effect and myocarditis
AI-generated summary
A 19-year-old Aboriginal woman with alcohol and cannabis abuse died at Graylands Hospital from combined drug effect and myocarditis. Following two suicide attempts within 48 hours, she was sedated and transferred via Royal Flying Doctor Service from Broome to Perth. A critical medication error occurred: nursing staff prepared a syringe containing 200mg/40ml of haloperidol instead of the intended 5mg/1ml concentration. Flight nurse administered 50mg total (two 25mg doses) believing they were 5mg each. The error was not clearly communicated to receiving doctors. On admission to Graylands, the psychiatrist misread the dosage as 2.5mg and did not arrange cardiac monitoring despite haloperidol's QT-prolonging effects. Inadequate observations at Graylands failed to detect deterioration. Clinical lessons: verify drug concentrations against source ampoules, clearly document medication errors in handover, communicate critical information to receiving teams, provide appropriate ECG monitoring for high-dose antipsychotics, ensure adequate supervision of observations in psychiatric units.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
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
- Obtain comprehensive summary of all drugs and doses administered before RFDS handover; review totals and seek advice if daily maximums reached
- Limit use of drugs to recommended maxima, exceeding only with careful consideration of risks and benefits
- Adequately monitor all patients during transport with ECG monitoring where possible and review QT interval
- Implement cardiac monitoring if QT prolongation detected
- Notify receiving hospital in advance if patients exceeded recommended daily maximums, ensuring full medical assessment including 12-lead ECG on arrival
- Clearly document total doses of each drug on observation chart and discuss at handover
- Develop revised inter-hospital transfer forms to include information specific to sedated psychiatric patients and total doses of sedative medication in last 24 hours
- 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
- Increase clinical staff awareness of need for ECG monitoring for patients receiving more than 20mg haloperidol or droperidol within 24 hours
- Update sedation policy and guidelines with training for clinical staff
- Implement staff education in responses to critical incidents when errors occur
- Roll out revised curriculum for clinical observation training at all mental health in-patient units
- Establish formal procedures to ensure medication error information is passed to receiving facilities
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