Inquest Into The Death Of Sharyn Kaine

73y · Female·Multi organ failure due to adhesions related bowel perforation (surgically treated) and paracetamol-induced liver failure

Sharyn Kaine, a 73-year-old woman, died from multi-organ failure due to adhesions-related bowel perforation and paracetamol-induced liver failure. She was prescribed intravenous paracetamol 1g four times daily post-operatively, despite weighing only 39kg. The appropriate dose should have been 487-585mg. A junior doctor transcribed the original prescription into the digital medication system without detecting the error, and subsequent clinical teams failed to review the dosing. Paracetamol was administered intravenously 13 times over five days before liver failure developed. Key clinical lessons include: weight-adjusted dosing must be consistently applied; intravenous medications require 24-hourly review; liver function should be monitored when high-dose paracetamol is given; and electronic prescribing systems with built-in safety alerts are essential to prevent medication errors.