Coroner's Finding: Glenn, Millicent

89y · Female·acute-on-chronic renal failure on a background of ischaemic heart disease, hypertension, chronic congestive cardiac failure and gentamicin therapy

An 89-year-old Aboriginal woman with chronic renal impairment and congestive cardiac failure was prescribed gentamicin intramuscularly for a urinary tract infection caused by Klebsiella aerogenes. Gentamicin is nephrotoxic and contraindicated in renal failure. An equally effective oral alternative (norfloxacin) was available. The prescribing GP failed to order baseline renal function tests or implement monitoring during the nine-day course. The patient deteriorated with acute-on-chronic renal failure and died. The coroner found the death preventable. Key lessons: (1) avoid nephrotoxic agents when safer alternatives exist in elderly patients with renal impairment; (2) always check baseline renal function before gentamicin; (3) implement strict monitoring if gentamicin is used; (4) be aware that eGFR calculations may underestimate renal impairment in elderly patients; (5) provide specific clinical instructions to aged care staff when prescribing high-risk medications.