A tragic error in medication administration has been cited as partially contributing to the death of 73-year-old Sharyn Kaine at Canberra Hospital in October 2021. The ACT Coroner, Ken Archer, has concluded that an overdose of paracetamol, administered over five days, played a significant role in her demise, leading to liver failure and ultimately multi-organ failure.
Ms Kaine, who weighed only 39 kilograms at the time of her death, had been admitted to the hospital for surgery following complications related to her bowel. The subsequent incorrect administration of paracetamol intravenously, despite her low body weight, has raised serious questions about medication management and safety protocols at the hospital.
In early October 2021, Ms Kaine presented to Calvary Hospital, experiencing significant lower abdominal pain. Further investigations revealed a suspected bowel perforation, prompting her transfer to Canberra Hospital for urgent surgery. During the procedure, a hole in her intestine was identified and repaired. Although the surgery was considered successful, Ms Kaine’s condition worsened in the following days.
Her medical history included a pancreatic cancer diagnosis in 2011, which had resulted in the removal of parts of her intestine, gall bladder, and pancreas. Despite this, Ms Kaine had generally been in good health before her hospitalisation.
Prior to surgery, Ms Kaine was prescribed paracetamol to manage her pain. Initially, a dosage of one gram, administered four times daily, was prescribed. However, a doctor later adjusted the dosage to 600mg, noting that the original amount was too high for someone of Ms Kaine’s slight frame.
Tragically, this dosage adjustment was overlooked. A junior medical officer, responsible for transcribing medications into the hospital’s digital records, failed to notice the change. As a result, Ms Kaine continued to receive one gram of paracetamol intravenously, a dosage typically considered too high for her body weight, on 13 separate occasions over a five-day period.
On 7 October, Ms Kaine collapsed and was moved to the Intensive Care Unit, where she remained until her death two days later. Despite her family being informed that she had less than 24 hours to live, Ms Kaine passed away just hours after this conversation.
Coroner Archer highlighted serious concerns about the hospital’s medication management process. He pointed to “shortcomings” in how medications were charted and entered into digital systems, which ultimately led to the tragic overdose. Additionally, he noted that at the time of Ms Kaine’s death, Canberra Hospital did not have specific procedures in place for paracetamol administration, leaving a significant gap in patient safety protocols.
The hospital has since introduced a Digital Health Record and electronic prescribing system, which include weight-based dosage checks. However, Canberra Health Services admitted that risks remain, particularly for adults weighing less than 50 kilograms, and described rectifying these issues as a “high priority”.
In his report, Coroner Archer stressed that Ms Kaine’s case raised a public safety issue, particularly concerning the administration of medications like paracetamol. He urged Canberra Health Services to release data on adverse medication events, including those involving paracetamol, since the new digital system was implemented.
The coroner also acknowledged the immense distress caused to Ms Kaine’s family and extended his deepest condolences to them.
