Finding into death of Margaret Ann Yeomans

79y · Female·Rhabdomyolysis in a woman with multiple myeloma and renal impairment

Margaret Ann Yeomans, aged 79, died from rhabdomyolysis in the context of multiple myeloma and chronic renal impairment. A critical medication error occurred when rosuvastatin 40mg was dispensed instead of her prescribed simvastatin 40mg on 27 June 2016. The pharmacist's final check failed to identify the error, and when the patient's husband raised concerns about the different medication appearance, staff reassurance prevented correction. Mrs Yeomans consumed the incorrect high-dose statin for weeks before hospital admission with acute renal failure. The coroner found the dispensing error and pharmacist's failed verification were contributing factors to her death. Clinical lessons include: rosuvastatin carries higher myopathy risk than simvastatin at high doses in elderly patients with renal impairment; pharmacy verification systems must not be bypassed by reassurance without proper checking; and patient/family concerns about medication appearance should trigger immediate pharmacist review rather than dismissal.