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Home / New Zealand

Overdose contributed to hospice patient's death - coroner

By Nikki Papatsoumas
APNZ·
30 Sep, 2014 02:55 AM2 mins to read

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File photo / Thinkstock

File photo / Thinkstock

A Christchurch hospice has been told to review its practices after a coroner found a patient in its care was administered the wrong dosage of a pain relief drug and died four hours later.

Geoffery Alfred Haase, 73, died from complications of metastatic prostate cancer with an oxycodone overdose as a contributing factor, Coroner David Crerar has found.

In November 2013, Mr Haase was admitted to Nurse Maude Hospice in Christchurch as a result of his cancer.

In his finding, Coroner Crerar said Mr Haase was given oxycodone for pain relief. However, nurses misread the dosage charted by the doctor and instead of a dose of 2.5 milligrams, a dose of 25 milligrams was given.

Mr Haase's condition then deteriorated and he died.

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Shortly after Mr Haase died, a nurse at the hospice became aware of a drug administration error.

A doctor from the hospice told Coroner Crerar that she did not believe the error caused the death of Mr Haase, as he was already a "dying man".

The doctor told Coroner Crerar that Mr Haase died peacefully surrounded by his family, four and half hours after the dosage error was made.

As part of his inquiries, Coroner Crerar commissioned an independent report from a clinical pharmacologist from the University of Otago, Professor Evan Begg.

Professor Begg told the coroner that apart from the initial mistake, he believed staff behaved in an "exemplary manner" and although an error was made, it did not alter the ultimate prognosis.

Coroner Crerar made several recommendations to Nurse Maude hospice, to ensure there was not a repeat of events.

He asked that all Nurses at Nurse Maude Hospice reviewed their practice during busy shifts, and their practice when dispensing medicine.

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"It is essential, in a case such as the death of Geoffery Haase, that a problem is identified and acknowledged as soon as possible.

"Management of Nurse Maude Hospice should take a lead in the rest home/hospice profession to both draw the circumstances of the dispensing error to the attention of similar organisations in New Zealand and investigate further methods to avoid a recurrence."

Coroner Crerar said in its internal review Nurse Maude also created a number of recommendations to avoid the possibility of a repeat of events.

Comment was being sought from the hospice.

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