Woman in hospital for routine knee surgery dies due to clerical error on medical charts

Woman in hospital for routine knee surgery dies due to clerical error on medical charts | 12 Oct 2012

A SECRET investigation is under way into how a woman who went to hospital for routine knee surgery died an agonising death because of a clerical error.

The State Coroner heard how it took seven days for bungling hospital staff to discover they had made two separate medical charts for the woman, with paracetamol medications ordered and administered on both.

Five doctors and four nurses are reportedly under investigation by the secretive Australian Health Practitioner Regulation Agency.

The case was referred to AHPRA by Queensland’s Health Quality and Complaints Commission, which investigated the scandal after a coroner’s request.

The woman’s death is a tragedy the so-called watchdog agencies do not want you to read about.

They declined to provide details. The woman’s identity is unknown and the name of the hospital was suppressed.


The investigation was so secret Health Minister Lawrence Springborg didn’t know about it and senior staff from his office were rebuffed when they sought details from the HQCC.

A cover-up continues, with Queenslanders – and Parliament – not told whether those responsible were admonished.

It is known that a confidential investigation ordered by the HQCC concluded the medical team at an unnamed Brisbane hospital showed “disregard for basic medication safety practices”.

The HQCC would not release the damning report, even to Mr Springborg. The so-called medical watchdog would not even say who conducted the inquiry.

The case highlights the lack of accountability and transparency in the medical industry and the treatment of negligence allegations.

A brief “case study” tabled in Parliament said the tragedy began when a woman went to hospital for an elective total knee replacement.

“Three days after surgery the woman became unwell,” it said.

“She had not had a bowel motion after the operation and was experiencing persistent nausea and vomiting.

“The woman was diagnosed with a partial bowel obstruction.

“A nasogastric tube was inserted to feed her (so she was nil by mouth) and she was given intravenous (IV) fluid therapy and a blood transfusion.

“Over the next three days, the woman’s condition improved and an oral diet was gradually re-introduced.

“Two days later the woman developed signs of another bowel obstruction, including vomiting, abdominal distention and pain . . . and she became increasingly dehydrated.

“After another two days, a nurse discovered that the woman had two separate medication charts, with paracetamol-based medications ordered and administered on both.

“The woman had therefore inadvertently received excessive amounts of paracetamol throughout the post-operative period.

“She was immediately started on treatment for paracetamol toxicity but her condition continued to deteriorate.”

Near death, her family members elected to cease active resuscitation and she died shortly after.

“A coronial autopsy found the woman died of multiple organ failure due to, or as a consequence of, drug toxicity, predominantly paracetamol,” Parliament was told.

With the help of an independent clinician the HQCC reported a “concerning pattern of disregard for basic medication safety practices across health professions”.

12/12/12 | The Courier-Mail

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