Coroner's Finding: HERBERT Raelene Vicki

29y · Female·respiratory depression caused by morphine intoxication on a background of upper airways narrowing as a consequence of infectious mononucleosis

A 29-year-old woman with infectious mononucleosis and severe sore throat died from respiratory depression caused by morphine intoxication with concurrent upper airway narrowing. A GP administered 30mg intramuscular morphine twice within 12 hours (2 doses totalling 60mg) based on an outdated weight-based dosing calculation rather than the recommended age-based approach (7.5-15mg for a 29-year-old). The woman was morphine-naïve, making her vulnerable to respiratory depression. At hospital admission, nursing observations were inadequate: the door was closed, two nurses miscommunicated about monitoring duties, and no observations were documented for over 2 hours. Peak morphine concentration coincided with the 2am check that was not performed. Critical lessons include: correct morphine dosing based on age not weight; morphine contraindicated in acute migraine; mandatory documented observation protocols when opioids administered, especially in morphine-naïve patients; clear nurse communication and supervision. The coroner found suitable guidelines could have prevented this death.