Finding into death of Dane Alexander Hortle

2y · Male·Tramadol toxicity in the setting of adenotonsillectomy in a child with Pierre Robin Sequence; extensive cerebral infarction secondary to respiratory depression

Dane Hortle, a 2-year-old with Pierre Robin Sequence and obstructive sleep apnoea, died from tramadol toxicity following adenotonsillectomy. He was discharged with a prescription for tramadol 25mg, which was dispensed as Tramal Oral Drops (100mg/mL) by a community pharmacy rather than the hospital pharmacy. Parents administered 10 drops (approximately 50mg per dose) twice at home. Toxicology revealed excessive tramadol levels (1.4mg/L), well above therapeutic concentrations. The child deteriorated overnight with respiratory depression, seizures, and severe hypoxic-ischaemic brain injury, leading to death despite intensive care. Key clinical failures included: the prescribing doctor not specifying tablet/capsule formulation despite knowing oral drops posed overdose risk; lack of clear warning about side effects and toxicity; and dispensing a concentrated paediatric formulation not approved for children under 12 years. System improvements at RCH post-death included explicit warnings against oral drops, encouraging hospital pharmacy use, and revised post-operative protocols.