Coronial
WAhospital

Inquest into the Death of Marjorie Joy JARICK

Deceased

Marjorie Joy JARICK

Demographics

54y, female

Date of death

2013-07-10

Finding date

2017-08-23

Cause of death

Opioid toxicity (predominantly fentanyl)

AI-generated summary

54-year-old woman with diabetes, obesity, and multiple opioid allergies underwent groin surgery at a private hospital. Anaesthetist Dr Y. prescribed a 75mcg/hr fentanyl patch post-operatively for chronic pain management due to the patient's intolerance of oral opioids. The patient had been reviewed by pain specialist Dr H. who recommended methadone instead, but this consultation was not communicated to Dr Y.. The patient vomited medications on the evening of 9 July and developed reduced oxygen saturation (94%), but was re-dosed with methadone without escalation to the anaesthetist. She was found unresponsive after midnight and could not be resuscitated. Death was attributed to opioid toxicity from the combination of fentanyl patch and other opioids. Clinical lessons include: avoid fentanyl patches in perioperative settings except for chronic pain patients; ensure communication between specialists about pain management plans; implement enhanced monitoring protocols (at least 2-hourly observations) when opioids are started; escalate respiratory depression signs (low oxygen saturation plus vomiting) to senior medical staff; and restrict fentanyl patch prescribing to specialists only.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

anaesthesiasurgerypain medicine

Error types

medicationcommunicationmonitoringdelay

Drugs involved

fentanylmethadonepethidinemorphinecodeineamitriptylineparacetamol/codeine/doxylaminemetoclopramide

Clinical conditions

opioid toxicityrespiratory depressiongroin cellulitis and infectiontype 2 diabetes mellitusobesitycoronary artery atherosclerosispulmonary oedema

Procedures

excision of lesion in supravaginal areaexploration of right groingeneral anaesthesiafentanyl patch application

Contributing factors

  • Inappropriate use of fentanyl patch in perioperative setting despite product information contraindication
  • Failure to communicate between anaesthetist Dr Y. and pain specialist Dr H. about perioperative pain management plan
  • Inadequate opioid tolerance calculation; 75mcg patch was substantial increase over baseline
  • Insufficient monitoring of oxygen saturation and level of consciousness post-operatively
  • Re-administration of methadone after vomiting without assessing cause or escalating to anaesthetist
  • Nursing staff contacted surgeon rather than anaesthetist when complications arose
  • Patient's obesity and smoking history predisposing to sleep apnoea and respiratory complications
  • Fentanyl patch dose accumulation reaching maximal effect approximately 24 hours post-application

Coroner's recommendations

  1. Amend the Department of Health Schedule 8 Medicines Prescribing Code to limit authorisation to prescribe fentanyl transdermal patches to approved specialists for pain management, using the current methadone prescribing system as a model
  2. Implement mandatory perioperative communication protocols between anaesthetists, surgeons, and pain specialists when chronic pain patients require surgery
  3. Establish enhanced opioid monitoring protocols including at least 2-hourly observation intervals when opioids are newly commenced or doses increased, with specific attention to oxygen saturation and level of consciousness
  4. Develop clear escalation pathways requiring nursing staff to contact the anaesthetist (rather than only the surgeon) for opioid-related complications such as vomiting, reduced consciousness, or respiratory depression
  5. Provide education to nursing staff and junior doctors regarding recognition of opioid toxicity signs and the need for rapid assessment before re-dosing after vomiting
  6. Restrict fentanyl patch initiation in perioperative settings to anaesthesia and pain medicine specialists only, with clear contraindication warnings in hospital protocols
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