Three older Australians have died in what a Victorian coroner has described as entirely preventable medication errors, prompting renewed calls for stronger national medication safety standards across residential aged care.
The deaths, which occurred at three separate Victorian aged care homes, have exposed serious concerns about medication administration practices, emergency response procedures, and broader systemic safeguards designed to protect some of Australia’s most vulnerable people.
In findings handed down this week, Victorian Coroner Ingrid Giles concluded that each of the deaths could have been avoided and warned that without stronger national reforms, similar tragedies remain a real risk.
Although the three incidents occurred at different facilities under different providers, the coronial investigation found striking similarities.
In each case, a resident was mistakenly given medication intended for another person. The errors were reportedly linked to factors such as staff distraction and failures in medication administration processes.
The investigation also found that in two of the three cases, staff delayed calling emergency services despite the residents rapidly deteriorating.
Coroner Giles said the combination of medication errors and delayed emergency responses highlighted significant safety issues within residential aged care.
She recommended the Australian Government urgently progress national medication management standards specifically tailored to aged care settings.
The coronial findings examined the deaths of three Victorian residents between 2024 and 2025.
One resident, 94-year-old Rosemary Jacoby, died after being given multiple medications intended for another resident. CCTV footage reportedly showed medications for several residents being prepared in unlabelled cups before a distraction occurred, resulting in the wrong medication being administered.
Although staff recognised the error, emergency services were not contacted immediately. When paramedics arrived, they reportedly found Ms Jacoby unconscious and alone.
Another resident, identified only by the pseudonym LV to protect her privacy, was accidentally given another resident’s medication after a nurse on their first day at the facility became distracted by a phone call during the medication round. She suffered seizures and deteriorated rapidly before later dying.
The third resident, Lynette McHarry, died after mistakenly receiving another resident’s medication at a Melbourne aged care home. Despite becoming increasingly unwell and later suffering a fall, an ambulance was not called until several hours after her condition had significantly worsened.
The investigation also revealed these were not isolated incidents.
Coronial findings noted medication errors have now been linked to the deaths of six Victorian aged care residents since October 2021, with medication mistakes also potentially contributing to another four deaths during the same period.
The findings have intensified concerns about whether current safeguards are sufficient to prevent serious medication incidents in residential aged care.
The findings echo concerns previously raised by the Inspector-General of Aged Care, who warned the coroner that older Australians will continue to face unnecessary risks until consistent national medication safety standards are introduced.
The Inspector-General also questioned whether existing reporting systems adequately capture the true scale of medication errors occurring in aged care or identify the systemic issues behind them.
Without accurate reporting, opportunities to identify recurring risks and prevent future incidents may be missed.
Medication management is one of the most complex responsibilities within residential aged care.
Many residents take multiple prescription medicines each day, often at different times and in carefully managed doses. This complexity increases the potential for serious harm if medications are administered incorrectly.
Research has consistently shown medication errors remain one of the leading patient safety risks across healthcare, particularly for older people living with multiple chronic conditions.
Experts say strategies such as barcode medication administration, electronic medication management systems, clearer medication labelling, minimising interruptions during medication rounds and ongoing staff education can all reduce the likelihood of errors.
The three providers involved have each undertaken internal reviews following the deaths and introduced additional safeguards aimed at preventing similar incidents.
While the specific changes differ between organisations, they include strengthened medication administration procedures and other safety improvements.
The coroner acknowledged these efforts but concluded broader system-wide reform is still required to better protect aged care residents across Australia.
The findings are likely to add further momentum to long-standing calls for nationally consistent medication management standards as governments continue implementing broader aged care reforms following the Royal Commission into Aged Care Quality and Safety.
