Coroner's Finding: PAULEY Cynthia Joy

72y · Female·Intrathecal toxicity of bupivacaine and morphine

A 72-year-old woman with terminal metastatic parotid cancer died from intrathecal toxicity of bupivacaine and morphine. She was admitted to Ashford Hospital for pain management of pathological pelvic fractures. An intrathecal catheter was correctly inserted but on 20 September 2010, a senior palliative care physician ordered a bolus dose of 5mg morphine and 3ml bupivacaine, intending epidural administration but the line was intrathecal. These doses were excessive for intrathecal delivery. The patient collapsed within 35 minutes, with profound hypotension (56/32) and respiratory depression. She received naloxone, briefly improved, then deteriorated again and died 4 hours later. The coroner found no alternative anatomical cause. Clinical lessons: verify catheter type before administration, implement enhanced monitoring after intrathecal bolus dosing, clarify resuscitation plans early in dying patients, and involve family in resuscitation decisions when acute medical events occur.