Jun 05, 2020

Coroner could not determine if medication error caused elderly woman’s death

The ACT Coroner says he was not able to determine if a medication mix up contributed to the death of an elderly woman in 2016.

Viola Clarke died on 20 February 2016, with the cause of death recorded as aspiration pneumonia.

But two days later, Dr Carolyn Droste referred the case to the coroner, following an allegation that two weeks prior Ms Clarke had been given the wrong medication at the nursing home where she lived, and the medication may have “caused or contributed” to her death.

Medication given to the wrong resident

On 9 February 2016, Ms Clarke was given the wrong medication. But Coroner James Lawton noted the error was “immediately detected” and the proper protocols were put in place: Ms Clarke’s family, her GP and other medical authorities were notified to “deal with the consequences”.

An ambulance was called that night, but Ms Clarke appeared well and was not taken to hospital.

But her condition “worsened” overnight, according to the coroner, and on 10 February Ms Clarke was taken to Canberra Hospital.

As well as experiencing the effects of the medication error, Ms Clarke was also suffering from congestive heart failure, chronic obstructive pulmonary disease, acute on chronic renal failure, gastric reflux, and dysphagia.

Ms Clarke passed away on 20 February.

Coroner unable to determine aspiration timing

The coroner was not able to determine if the medication contributed to Ms Clarke contracting aspiration pneumonia.

“It was possible that she aspirated before being given the wrong medication; after being given the wrong medication but before being admitted to the Canberra Hospital; or after she was admitted to the Canberra Hospital,” the coroner said in his findings.

“Ultimately I am unable to be comfortably satisfied that the erroneously-given medication caused or contributed to the aspiration that led to Mrs Clarke developing aspiration pneumonia as I cannot be comfortably satisfied as to when that aspiration (or aspirations) occurred,” he said.

Aged care nursing careers should be promoted, coroner said

Coroner Lawton said Australia’s aged care system will need to “consistently expand” to meet the increased burden placed on it from the ageing population.

In his recommendations, he said the aged care industry should be promoted as an attractive option for graduate nurses.

He said aged care facilities should be given support to conduct graduate programs for nurses allowing them to attain a speciality in geriatric care.

He said endorsed enrolled nurses should be given increased “scope of practice” in their roles.

Confirm resident’s identity before administering medication

Medication has long been described as a ‘wicked’ problem in aged care. 

Between January and March 2020, the Aged Care Quality and Safety Commission received 203 complaints about ‘medication management’, the largest total equal with ‘personnel numbers/sufficiency’.

This case highlights the importance of staff training and protocols around the administering of medication in protecting the recipients of aged care services.

Though in this case the coroner could find no direct link between the medication error and Ms Clarke’s passing away, medication errors can, and do at times, have the most serious of consequences. 

Image: Moussa81, iStock.

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