Coroner's Finding: Teressa Beswick

45y · Female·Combined effects of widely metastatic (end-stage) carcinoma of the cervix and bronchopneumonia

Teressa Maree Beswick, a 45-year-old woman with end-stage metastatic cervical cancer, died from the combined effects of her cancer and bronchopneumonia accelerated by a critical medication error. On 23 October 2014, she presented to Mersey Community Hospital with severe pain. A career medical officer made a decimal conversion error when switching her from fentanyl patches to morphine syringe driver, prescribing 45 mg per hour instead of 45 mg per 24 hours—a 24-fold overdose. The syringe driver was calibrated to deliver 1080 mg daily instead of approximately 120 mg. Despite multiple staff members—nurses, pharmacist, and a registrar—expressing concerns that the dose seemed excessive, no one escalated appropriately or performed independent verification. Over 12 hours, the patient received ~496 mg of morphine, causing severe respiratory depression and opioid toxicity. While the patient was terminally ill with imminent death from advanced cancer, the overdose accelerated her death. The coroner recommended that MCH review its pharmaceutical protocols to implement safeguards preventing such drug overdoses.