Inquest into the Death of Partington

88y · Female·pneumonia and morphine toxicity in an elderly lady with a recent left leg and left arm fracture

Pauline Margaret Partington, an 88-year-old woman, suffered an unwitnessed fall at a residential aged care facility on 4 May 2008 and sustained a fractured left neck of femur, displaced fracture of the left humerus, and pneumonia. She was transferred to Albany Regional Hospital where medical assessment determined she was too frail for surgical intervention. A palliative care approach was adopted with high-dose morphine for pain management. She died on 5 May 2008 from pneumonia and morphine toxicity. The inquest identified significant issues with Schedule 8 drug record-keeping, including inconsistent documentation of morphine doses, lack of clear procedures for recording discarded medications, and confusing dual recording of bolus doses from infusions. The coroner made three recommendations: implementing separate columns in drug registers to record discarded Schedule 8 medications with witness signatures; establishing uniform state-wide procedures for disposing of unused Schedule 8 medications; and reviewing medication documentation to prevent confusion when bolus doses are administered from infusions.