Grandmother's death at Canberra Hospital was partially due to paracetamol overdose

A coroner has found a woman’s death at the Canberra Hospital was partially due to an overdose of the pain-killer paracetamol that she received while undergoing treatment at the facility.

Sharyn Kaine was a 73-year-old “loving grandmother” who died on 9 October 2021, ACT Coroner Ken Archer said when handing down his findings on the inquest into her death earlier this week.

She was initially taken to the then-Calvary Hospital for lower abdominal pain, then was transferred to the Canberra Hospital for a suspected bowel perforation.

Her condition stabilised after what was thought to be a successful surgery on 3 October 2021, but she suddenly deteriorated on 7 October and was found to be seriously unwell with signs of organ failure.

“Prior to her collapse, she had been given paracetamol intravenously,” Coroner Archer said.

“It was suspected that she had been administered a paracetamol overdose. Attempts to treat that issue were unsuccessful.”

The coroner said the only real issues in the inquest were whether an overdose of paracetamol was given to Ms Kaine and, if so, whether that overdose caused or hastened her death.

On 2 October 2021, Ms Kaine, who weighed 39 kg, was prescribed one gram of paracetamol four times a day, but this was then cancelled by a doctor before her surgery. The doctor told the inquest that while this was a standard adult dose, given her size, he thought it was a “large” dose and asked for a dose of 600 mg four times a day.

She was given one such dose. However, Coroner Archer said one gram of paracetamol was then given to her intravenously on 13 occasions over five days.

He said this was due to a transcription error in the digital medication records, the failure to incorporate the doctor’s changes into the medication chart, or the failure to review Ms Kaine’s paracetamol dosing levels.

She collapsed on 7 October, and it was found she was undergoing liver failure due to potential paracetamol toxicity. Staff thought her organ failure was not survivable, and she died on 9 October.

According to a representative from the medication safety and quality team at the hospital’s pharmacy, Ms Kaine’s dose of one gram of paracetamol four times a day “exceeded both the maximum amount per dose and the maximum per day”.

She said the dose shouldn’t have been more than about 585 mg every four hours due to her weight.

Professor Johan Duflou, who conducted the autopsy, found her cause of death was “adhesions-related bowel perforation (surgically treated) and possible paracetamol-induced liver failure”.

Coroner Archer said due to the professor’s opinion, it was not open for him to find the paracetamol overdose was the only cause of death.

He found she died of multi-organ failure related to her bowel perforation as well as paracetamol-induced liver failure.

He also found the inquest revealed a matter of public safety because, at the time of her death, the hospital did not have specific procedures or guidelines for paracetamol administration.

However, since her death, the hospital no longer uses the former medication records and has switched to the Digital Health Record.

A Canberra Health Services (CHS) spokesperson said the service extended its sincere condolences to Ms Kaine’s family and acknowledged the grief, loss and sadness they have experienced.

“We will review the findings and make necessary changes to our systems and processes to ensure CHS continues its commitment to patient safety,” the spokesperson said.

“With respect to oral paracetamol administration alerts for some types of patients, CHS is working to improve the functionality of the Digital Health Record to provide alerts and dosage recommendations for oral paracetamol to address these concerns. This is a high priority.

“We will continue to consider further opportunities to improve our systems and processes and keep improving the quality of services to our patients.”

Coroner Archer recommended CHS publish statistical material identifying trends in adverse medication outcomes at the hospital since the introduction of the DHR, including adverse outcomes involving paracetamol.

“I acknowledge that Sharyn’s passing has caused great distress to her extended family. I offer my sincere condolences. I am grateful for the role that [her daughter] Danielle has played in my investigation,” he said.