Finding into death of Rosemary Elsie Harriet Jacoby

94y · Female·Drug toxicity (baclofen, gabapentin, oxycodone, pregabalin, zolpidem)

A 94-year-old residential aged-care resident died from drug toxicity after receiving another resident's medications. An agency nurse, unfamiliar with the patient and interrupted during medication preparation, failed to perform standard patient identification checks required by the 'six rights' of medication administration. The medications administered in error included multiple sedatives (oxycodone, baclofen, gabapentin, pregabalin, zolpidem) with additive effects. Critically, staff failed to escalate appropriately: they arranged only a locum GP review instead of calling emergency services immediately; 000 was called approximately one hour later. By hospital arrival, the patient was critically unwell. Despite appropriate emergency treatment including naloxone reversal, recovery was impossible due to drug toxicity combined with advanced age and underlying cardiac disease. The coroner found the death preventable. Key systemic failures: aged-care facilities lack medication-specific safety standards; agency staff receive inadequate supervision and orientation; there is no 24/7 on-site medical oversight for escalation decisions.