Woman given paracetamol in Canberra Hospital died of partial overdose, coroner’s report finds

Sharyn Kaine, 73, weighed just 39kg when she died in Canberra Hospital on October 9, 2021.

Now a coroner has found medicine charting processes at the hospital led to a paracetamol overdose of the “loving grandmother”.

An initial standard adult dose of 1g of paracetamol was later weight-adjusted to 600mg, however, that change was not reflected when handwritten charts were entered into the hospital’s electronic medication record, ACT coroner Ken Archer said in findings published on Tuesday.

Kaine, who had undergone surgery to treat a bowel perforation, was given the incorrect 1g dosage of paracetamol intravenously on 13 occasions over five days as she recovered in hospital, before her organs began to fail and she died.

An autopsy ruled the partial cause of death was liver failure due to paracetamol toxicity.

The inquest heard Kaine, who had undergone surgery and treatment for pancreatic cancer in 2011, went to Calvary Hospital a decade later with abdominal pain on October 2, 2021.

She was transferred to Canberra Hospital where she underwent surgery to treat a bowel perforation the following day, October 3.

The surgery reportedly “went well” and Kaine was moved to a ward where, despite some lingering pain, she was recovering and undergoing physiotherapy reviews as she regained her mobility.

But on October 7, just days after the operation, she collapsed and was rushed into intensive care where she died just after midnight on October 9.

The inquest heard that a hospital doctor had initially prescribed 1g of paracetamol four times a day for Kaine.

However, before her surgery, the attending doctor deemed that standard adult dosage to be too much for the 39kg woman and it was changed to a weight-adjusted dosage of 600mg on Kaine’s handwritten medical chart.

At some point before Kaine was moved to a ward, her handwritten chart was entered into an electronic medical record by a junior medical officer — who entered the 1g dosage.

The junior medical officer said she did not see the doctor’s note on the handwritten chart, and did not know whether the updated dosage of 600mg was made before or after she had transcribed the chart to the digital record.

The coroner’s report found Kaine subsequently received the larger 1g dose 13 times before her collapse on October 7.

By the afternoon of October 8, Kaine’s family were told she would die within 24 hours.

She was declared dead just after midnight.

“Sharyn’s condition deteriorated quickly, which, unfortunately, restricted the opportunity for all of the family members to be present when Sharyn passed away,” Archer said.

As well as paracetamol toxicity, the post-mortem examination also found “other changes in the body which were largely considered the result of sepsis, multiple organ failure and markedly deranged metabolic processes,” Archer said.

“Whether these were the result of the initial bowel perforation, or a consequence of paracetamol toxicity, or both processes, is not able to be determined.”

Issues with a manual and digital overlap

The death highlighted issues with the hospital’s operations, Archer found.

It did not have any specific organisational procedures or guidelines about paracetamol administration at the time.

The electronic Digital Health Record (DHR), which had already been brought in by the hospital at the time of Kaine’s death, had already made the handwritten chart “redundant,” Archer said.

The DHR is being relied upon in hospitals, including Canberra Hospital, for improved patient outcomes — it has a function to predict overdoses before they happen by comparing input dosages and weights. But it doesn’t guarantee against overdoses, as weights entered incorrectly can still lead to overdose.

Still, Archer recommended the hospital publish statistical data on adverse health outcomes, including non-fatal outcomes and those involving paracetamol, to identify trends and to identify the efficacy of the DHR since its implementation.

Archer acknowledged the “great distress” that Kaine’s death caused her extended family.

“I offer my sincere condolences,” he said.