Coroner's Finding: RUSSELL Brian Edward

80y · Male·bronchopneumonia complicated by morphine toxicity

An 80-year-old man with terminal liver disease died from bronchopneumonia complicated by morphine toxicity following a medication administration error. A Graseby infusion pump was incorrectly set at 99mm/hour instead of the intended 1mm/hour, delivering the entire 10-hour dose within 15 minutes. The nurse who set the pump had no prior experience with this device, did not consult the procedure manual or more experienced colleagues, and attempted correction with a paperclip rather than seeking proper assistance. After the overdose was discovered, naloxone was administered, then additional morphine was given despite ongoing signs of distress. The case highlights critical failures in equipment training, procedural compliance, and post-incident management, with nursing staff removing evidence before coronial investigation could occur. Proper training, equipment maintenance, procedure standardisation, and incident response protocols would have prevented this death.