Morphine overdose ‘enough to kill a whole paddock of horses’

Mersey Community Hospital

Daughter of a woman who died from hospital overdose says the doctor ignored a pharmacist who queried the dose

A Tasmanian coroner has highlighted significant shortcomings of a hospital pharmacy following the death of a woman who was “grossly” overdosed with morphine.

State coroner Rod Chandler recommended Mersey Community Hospital, based in north-west Tasmania, review its pharmaceutical protocols with the aim of reducing the risk of drug overdoses, according to a report by The Advocate.

Chandler found that aged care worker Teressa Beswick died after she was given “nine times the maximum effective dose of morphine”, which he described as a “most inappropriate” dose.

He found that the cause of death was a combination of factors: metastatic carcinoma of the cervix and bronchopneumonia, with the morphine overdose playing a secondary role in her death because it accelerated Beswick’s death by a relatively short period.

Beswick went to the hospital’s emergency department for palliative pain relief in October 2014 and died the next day.

While at the hospital she received 497mg of morphine, which according to her daughter Taneka Parker “was enough to kill a whole paddock of horses”.

Parker said she wanted to alert community members to what could happen when a doctor would not listen to nurses nor a pharmacist who queried the dose.

The coroner said there were serious concerns about the safeguards around dispensing questionable prescriptions at the Mersey Community Hospital.

Beswick had been using fentanyl patches, which it was agreed would be replaced with morphine using a syringe driver at the hospital.

Chandler noted that the doctor, Dr Rajesh Menon, acknowledged that in making the dose calculation he had not realised that the 45mg morphine dose, which a conversion table showed to be the right amount, was for a day and not an hour.

As a result, Beswick’s syringe driver was calibrated to deliver 24 times the intended dose for about 12 hours.

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  1. pagophilus

    And this shows that pharmacists and nurses need to be able to refuse to supply/administer until they receive an order/prescription they are satisfied with.

    • Jarrod McMaugh

      Pharmacist already can refuse to supply. That’s exactly what should have happened here.

      The role of pharmacists includes protecting patients from the mistakes of other health professionals. The pharmacist should have calculated the dose and prevented it from being administered.

      • Max

        Totally agree. As a pharmacist, I can’t defend that one.

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