Finding into death of Glen David Kingsun

42y · Male·Cardiac arrhythmia secondary to electrolyte imbalance (hyperkalaemia) and verapamil toxicity

Glen Kingsun, 42, died from cardiac arrhythmia secondary to electrolyte imbalance and verapamil toxicity. He had complex medical needs requiring multiple specialist and GP care. Critical failures occurred: (1) Medication coordination – multiple doctors prescribed without complete awareness of other medications, leading to likely verapamil overdose (toxic combination with propranolol). Dr B. prescribed diltiazem 320mg mistakenly, Dr N. then increased verapamil to 420mg daily attempting to fulfill what he misunderstood. (2) ED response – on second presentation with bradycardia, hyperkalaemia, and ECG changes suggesting life-threatening electrolyte disturbance, staff failed to recognise severity, didn't triage as category 2, and delayed treatment until asystole occurred. The coroner found a failure to recognise deteriorating condition and misinterpret life-threatening ECG findings. A real-time prescription monitoring system could have prevented this tragedy.