Finding into death of Phillip Harry Parker

61y · Male·Pneumonia

A 61-year-old man with significant medical complexity including acquired brain injury, bronchiectasis, pulmonary fibrosis, and dysphagia died from pneumonia 26 days after receiving another resident's slow-release opioid medication in error at an aged care facility. A patient care worker administered Tapentadol SR 100mg intended for another resident due to lapses in concentration during a busy shift with interruptions. The medication error was identified promptly and the patient was reviewed by two locum doctors who diagnosed pneumonia and prescribed antibiotics. The coroner found no evidence the medication error caused the death, which occurred in the setting of significant functional decline over nine months. However, system failures including inadequate staffing ratios, skill mix, and use of unqualified staff to administer high-risk Schedule 8 medications contributed to the error. The case highlights risks of permitting patient care workers to administer opioids in aged care when hospitals use strict dual-registered nurse protocols.