Patient’s death on stroke/neurology ward was preventable: coroner


By Tessa Hoffman

18 Oct 2018

A series of critical errors and failings on a stroke and neurology ward led to the preventable death of a man from opioid toxicity at an Adelaide public hospital, a coroner has found.

Stephen Atkins died from fentanyl and oxycodone toxicity after being admitted for treatment of neuropathic pain at Flinders Medical Centre in March 2015.

What should have been a short stay for the non-life threatening conditions of Horner’s Syndrome and right arm radiculopathy ended in the death of the 53-year-old man from opioid toxicity, a coronial inquest has been told.

The inquest heard that a series of critical errors and omissions were made, including failure of medical staff to review the patient’s notes and failure of nursing staff to record or act on the patient’s vital signs.

The opioid medications prescribed for the deceased would, if taken alone would “not necessarily have posed a risk”, said South Australia Deputy Coroner Jayne Basheer in her finding on October 10.

However, the combination of oxycodone, subcutaneous fentanyl and slow-release Oxycontin posed a high risk because they were given at too-frequent intervals by medical staff who admitted they had little experience in prescribing opioids.

Doctors told the inquest that in hindsight they would have referred the patient to the Acute Pain Service for review, but a series of communication and handover errors meant they did not see information in his notes that he was receiving large amounts of PRN opioids and responding poorly, with continuing high levels of pain.

The coroner noted that stroke consultant Dr Lata Cheruvu did not look at the patient’s progress notes or medication charts because she had an extremely high workload trying to manage 16 patients in her role as on-call dual consultant covering both stroke and geriatric units, and was called away to an emergency.

“The decision to continue PRN medications without sighting and assessing the patient’s medication chart and reading the progress notes (or ensuring that their contents were brought to her attention) falls far short of the standards of care one would ordinarily expect of a senior consultant,” the coroner said as part of her findings.

The coroner was also highly critical of nursing staff who failed to record vital signs such as low oxygen saturation in the patient’s charts, and their failure on multiple occasions to trigger the escalation pathway and medical review when his observations went into the ‘red zone’.

Over the three days, there were many occasions where nursing staff missed opportunities to intervene or escalate care in line with hospital protocols, Coroner Basheer said.

“These failures removed real opportunities for interventions, any one of which could have potentially have changed the ultimate outcome for Mr Atkins and his family.”

The inquest also heard from pain specialists who said opioids often achieved little response in neuropathic pain and their continued use should be reviewed if ineffective as they were high risk ‘life threatening’ drugs.

The coroner noted that changes had been made at Flinders Medical Centre in light of the incident, and she recommended that the practice of on-call specialist consultants being rostered to cover dual specialities be stopped.

She also recommended a review of the process of information sharing amongst medical and nursing staff with a focus on the handover process, and the use of progress notes as a primary information source.

Medical and nursing staff should also receive mandatory refresher courses on the risks of opioids, the coroner recommended.



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