Finding into death of Glenni Goodwin Ker

84y · Female·allergic reaction to metoclopramide (Maxalon) in a woman with acute myocardial infarction and ischaemic bowel

An 84-year-old woman with acute myocardial infarction (AMI) and ischaemic bowel died following an allergic reaction to intramuscular metoclopramide (Maxalon) administered by nursing staff without a doctor's order, despite the patient having a documented allergy (red wristband and medication chart notation). The nurse failed to check the patient's allergy documentation, ignored the patient's verbal warning, and failed to escalate the incident immediately. Key lessons: always verify drug allergies against multiple sources (wristband, alert sheet, medication chart) before administering any medication, particularly intramuscular injections requiring two-nurse verification; recognize and act on red allergy wristbands as mandatory triggers for documentation review; understand that nurse-initiated medications contravene policy when doctors are available; escalate incidents involving administered allergens immediately to prevent delayed recognition and treatment of allergic reactions.