Man presenting with headache pain dies from overdose of opiate drugs in private hospital.
Inquest into the death of Michael James Calder
Inquest Dates: 15 April 2016; 16-18 August 2016 (delivered 2 September 2016)
Coroner: John Lock, Deputy State Coroner
Inquest Place: Brisbane
Date of Death: 11 July 2014
Issues for Consideration:
- What was the cause of Mr Calder’s death?
- What were the circumstances leading up to Mr Calder’s death?
- Was the treatment provided to Mr Calder at the Holy Sprit Northside Private Hospital from his admission on 8 July 2014 up until his death appropriate?
Mr Calder, aged 33, died four days after his admission on 8 July 2014 to Holy Sprit Northside Private Hospital (“Holy Spirit”) for treatment of headache pain. His treating physician was unaware that Mr Calder had previously been treated for Obstructive Sleep Apnoea at the Holy Spirit.
Mr Calder was administered a complex regime of analgesia. The cause of his death was unexpected and uncertain.
- Counsel Assisting - M Jarvis
- Calder Family - Maurice Blackburn Lawyers
- Nurse Meadowfair - Creevey Russell
- Holy Spirit Northside Private Hospital (Holy Spirit) - Minter Ellison
Evidence and Investigations
Evidence of Dr Rodd Brockett (treating physician)
- On 9 July 2014, Dr Brockett first attended Mr Calder and noted that he had already been given 10mg IV morphine, 5mg of subcutaneous morphine, 10mg oxcycodone orally and was receiving 4 x 5mg daily doses of Endone. Dr Brockett ceased the regular Endone and prescribed twice daily doses of OxyContin of 40mg. He was also taking paracetamol and ibuprofen as needed.
- On 10 July 2014, Dr Brockett increased analgesia by giving Mr Calder 160mg per day of MS Contin in two divided doses and continuing with doses of Ordine as needed. He ceased OxyContin and started Gabapentin at 300mg.
- Dr Brockett was not aware of previous episodes of hypoxaemia on 8 July 2014 or of Mr Calder’s history of sleep apnoea. No Patient History form was completed at this time, therefore the fact of Mr Calder’s history of sleep apnoea was not made known to Dr Brockett of treating nurses.
- Dr Brockett noted that he routinely did not read the ED record because it was difficult to read. Dr Brockett therefore overlooked an entry in the ED records that at 19.20 hours Mr Calder had an episode where his oxygen saturations plummeted to 79%.
Root Cause Analysis (RCA)
- The RCA identified a failure by night shift nursing staff to recognise and respond to early signs of deterioration (oxygen saturation levels of 90% on 10 July 2014) as a factor that may have contributed to Mr Calder’s death.
- Following the RCA, Holy Spirit implemented several of the recommendations made.
- Holy Spirit acknowledged system issues in relation to clinical practice models for escalation processes, pain management and opioid usage.
- The provision of opioids to manage Mr Calder’s headache without conducting a focused assessment of pain management was another possible causal factor that may have contributed to Mr Calder’s death.
Expert review by Dr Charles Denaro (consultant physician and clinical pharmacologist)
- Dr Denaro did not believe that the treatment provided, clinical management, prescribing practices or investigation were appropriate.
- He opined the opiate dosing was inappropriate and excessive for an “opiate naïve” patient and this prescribing could have caused Mr Calder’s death.
- Additionally, Mr Calder’s sleep apnoea was made worse by the sedative properties of the opiates and this may have been a contributing factor to his death.
- Mr Calder’s deterioration was likely to have been caused by a combination of three factors including sleep apoea, opioid increase and the introduction of gabapentin.
Expert report by Dr Peter Lavercombe (intensive care specialist and general physician)
- Dr Brockett’s clinical decision regarding analgesia on 8 – 9 July 2014 was reasonable, with the exception of administering large doses of oral morphine. The decisions to commence slow-release oxycodone on 9 - 10 July 2014, in combination with the larger doses of short acting morphine as required, risked an accumulation of narcotics before the slow-release narcotic had reached maximum effect.
- The doses of morphine were excessive and were compounded by the use of short-acting narcotics, in a ward situation where monitoring was not rigorous and continuous.
- The framework for pain management adopted by Dr Brockett was appropriate for management of pain that is time-limited and where there is close observation and pulse oximetry. However, the conventional approach of starting with low doses of narcotics and titrating up was superior for treatment of what was expected to be chronic pain.
- The cause of Mr Calder’s death was opiate toxicity. The morphine level in his blood was well within the range considered to be potentially lethal, particularly when combined with the presence of oxycodone and gabapentin.
- In respect of the circumstances of Mr Calder’s death, the coroner found that:
- His treating physician was unaware that Mr Calder had previously been treated for Obstructive Sleep Apnoea at the Holy Spirit.
- Mr Calder’s treating doctor and nursing staff did not recognise the correlation between the medications provided and episodes of hypoxaemia suffered by Mr Calder at critical times during his admission.
- Dr Brockett did not have any discussion with nursing staff or give instructions for signs to look for in a patient subject to this kind of opioid treatment plan. While it was unclear whether this would have made a difference, such instructions may have prompted staff to express concerns regarding Mr Calder’s low oxygen saturations.
- The coroner made no further recommendations for implementation by Holy Spirit. Holy Spirit had achieved substantial compliance and knowledge of the outcome of the RCA recommendations. Holy Spirit replaced its existing early warning system observation chart with the Adult Deterioration Escalation Chart. Each clinical ward was to have a ward educator present for 8 shifts per fortnight. In addition, the Hospital obtained a Nellcor machine for the ward to continuously monitor oxygen saturations and pulse which automatically alarmed when certain parameters are exceeded.
- The coroner did not consider there was any need to refer treating nurses or Dr Brockett to any disciplinary bodies. Dr Brockett had clearly reflected on his part in the circumstances of Mr Calder’s death, that his medication regime was wrong. He had instituted a new framework for approaches to pain management.
Chronology of Events
|AM||Michael James Calder (aged 33) was referred by his general practitioner to the Holy Spirit Northside Private Hospital following three days of severe occipital headaches. His general practitioner noted that Mr Calder had a history of viral meningitis and had previously been diagnosed with severe obstructive sleep apnoea syndrome.|
|1440 hours||Mr Calder presented to the Holy Spirit Emergency Centre (“ED”) and a provisional diagnosis of viral meningitis was made. A lumber puncture and CT revealed unremarkable results. Mr Calder was given IV morphine of 10mg over a half hour period.|
|1920 hours||Mr Calder had an episode where his oxygen saturations plummeted to 79%.|
Mr Calder was admitted to the ward under Dr Rodd Brockett (general physician). ED provided a record and had a discussion with Dr Brockett in relation to Mr Calder. No Patient History form was completed at this time, therefore the fact of Mr Calder’s history of sleep apnoea was not made known to Dr Brockett of treating nurses.
|2200 hours||Endorsed Enrolled Nurse (EEN) Meadowfair commenced her night shift. Ms Meadowfair gave Mr Calder pain relief as he was experiencing a lot of headaches.|
|1400 hours||R.N. Goudswaard attended Mr Calder and observed that his oxygen saturations were 95% on room air.|
|0430 hours||Mr Calder was administered Ordine.|
|0715 hours||R.N. Roach and R.N. Juan administered 40mg OxyContin to Mr Calder.|
|0750 hours||R.N. Roach and R.N. Juan administered Mr Calder another 20mg dose of Ordine. They administered this after telephoning Dr Brockett regarding Mr Calder’s Ordine prescription, noting that it did not specify a frequency or maximum dose. Dr Brockett confirmed Ordine was to be administered third hourly.|
|0800 hours||R.N. Juan observed Mr Calder’s oxygen saturations were 85 – 88%. She applied oxygen.|
|1000 hours||R.N. Juan administered 40mg Ordine to Mr Calder.|
|1340 hours||R.N. Juan administered 40mg Ordine to Mr Calder.|
|1430 hours||R.N. Juan reviewed Mr Calder recording oxygen saturations of 93%. He was on 2 L oxygen. She noted that she administered regular midday 1g paracetamol and 400mg ibuprofen.|
|1645 hours||R.N Goudswaard administered 40mg Ordine as well as paracetamol and gabapentin.|
|1800 hours||R.N Goudswaard administered paracetamol and gabapentin.|
|2000 hours||R.N Goudswaard administered 80mg MS Contin, 400mg ibuprofen and Movicol and gabapentin.|
|2400 hours||EEN Meadowfair noted Mr Calder’s oxygen saturations were 90% but there was no note to indicate that she had used nasal prongs to introduce oxygen.|
|0440 hours||EEN Meadowfair checked on Mr Calder noting he was pale and hit the CODE BLUE cardiac arrest buzzer.|
|0441 hours||R.N. Ballinger heard the emergency call and arrived and commenced CPR on Mr Calder and R.N. Taylor brought the cardiac arrest trolley. Together, they attempted to resuscitate Mr Calder for approximately 30 – 45 minutes. They called in Dr Brockett and the Hospital coordinator. The ICU tema attended and took over arrest management.|
|0517 hours||Resuscitation efforts ceased and Dr Brockett declared Mr Calder deceased.|
|Autopsy revealed that the death was a result of opiate toxicity from both the combined effects of aspiration pneumonia and the immediate toxic effects of opiates on the central nervous system and respiration.|