Coroner Links Paracetamol Overdose to Grandmother's Death at Canberra Hospital

A paracetamol overdose has been identified as a contributing factor in the death of a woman at Canberra Hospital in 2021, according to findings from the ACT Coroner.

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Seventy-three-year-old Sharyn Kaine, who weighed only 39 kilograms at the time, died in hospital on October 9 after being administered intravenous paracetamol over five days.

Coroner Ken Archer reported that Ms Kaine first visited what was then Calvary Hospital earlier that month, complaining of lower abdominal pain. She was subsequently transferred to Canberra Hospital for surgical intervention due to suspected bowel perforation.

Following the surgery, Ms. Kaine’s condition deteriorated, leading to her death a few days later. An inquest revealed she died from multi-organ failure and liver failure caused by paracetamol overdose.

Hospital Admission for Abdominal Pain

Court documents indicate that Ms. Kaine had been generally healthy until her pancreatic cancer diagnosis in 2011, which resulted in the removal of parts of her intestine, gallbladder, and the head of her pancreas.

In October 2021, she experienced severe lower abdominal pain, a distended and painful abdomen, and difficulties urinating. A CT scan revealed an issue with her bowel, leading doctors to conclude that perforation was likely.

As a result, she was transferred to Canberra Hospital for surgery. During the operation, a hole in the intestine was found and repaired, and the procedure initially appeared to have gone well.

Dosage Change and Administration Error

The day before her surgery, Ms. Kaine was prescribed a dosage of one gram of paracetamol four times daily. However, one doctor considered this dosage excessive for her weight and altered the prescription to 600 mg.

Despite this change, a junior medical officer at ACT Health mistakenly entered the one-gram dosage into the electronic medication record without seeing the alteration. As a consequence, Ms Kaine received one gram of paracetamol intravenously 13 times over five days.

On October 7, Ms. Kaine collapsed and was transferred to the Intensive Care Unit. She passed away in the early hours of October 9, shortly after her family was informed that she would die within 24 hours.

Concerns Over Dosage

A member of the Medication Safety and Quality team at the hospital testified that the paracetamol dosage was “not … appropriate” for someone of Ms. Kaine’s weight. An autopsy confirmed that she died from multi-organ failure due to bowel perforation and paracetamol-induced liver failure.

The coroner identified an “input error” in the medication administration process and noted that public safety concerns arose from Ms. Kaine’s case. He found that the hospital lacked specific procedures for administering paracetamol at the time of her death, which contributed to the error.

In a response to the coroner, Canberra Health Services indicated that a Digital Health Record and an electronic prescribing system have since been implemented. This system includes weight-based checks and multiple opportunities to detect errors. However, they acknowledged the ongoing risks of administering inappropriate doses of oral paracetamol to adults weighing less than 50 kilograms, and addressing this issue remains a “high priority.”

Mr Archer encouraged Canberra Health Services to publish statistics related to adverse medication outcomes, particularly those involving paracetamol, since implementing the Digital Health Record. He extended his condolences to Ms Kaine’s family, acknowledging the profound distress her death has caused them.

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