A recent Coroner’s inquest has highlighted the risk of incorrect administration of medication and reinforced the importance of hospitals and aged care organisations ensuring good communication with a patient’s family in circumstances where a medical decision is made to impose an NFR order.


Maria Dolores Coleiro1 died on 22 September 2011 at Western Hospital in Victoria. She was 69 years old and had a significant medical history.

On 16 September 2011, Ms Coleiro underwent a biopsy at the hospital. The biopsy confirmed that the deceased had an infection and she was prescribed antibiotics by way of treatment. She was also diagnosed with aspiration pneumonia and a nasogastric tube (NGT) was inserted to assist with feeding and the administration of medications.

Ms Coleiro’s family were informed that she had a high mortality risk against the background of a significant infection, risk of continued aspiration and pneumonia, pre-existing dense hemiparesis, and poor cardiac function. In light of these conditions, a medical decision was made to not administer cardiopulmonary resuscitation (CPR) should her condition deteriorate. A Not for Resuscitation (NFR) order was subsequently drawn up.

On 22 September 2011, Ms Coleiro was incorrectly administered ciprofloxacin (an antibiotic) via her PICC line instead of her NGT. Shortly thereafter, she started breathing abnormally before becoming unresponsive.

It was the hospital’s policy that a code blue would always be called for an iatrogenic event such as the incorrect administering of medicine. However, the error by nursing staff was not immediately noticed nor attributed to Ms Coleiro’s decline.

As a result, a code blue was not called in recognition of the standing NFR order. CPR was not administered and Ms Coleiro was pronounced dead shortly thereafter.

Coroner’s findings and conclusion

1. Inadvertent administration of medication

The ciprofloxacin was administered to Ms Coleiro by a nurse who had no previous experience with PICC lines. The nurse realised almost immediately after Ms Coleiro had died that she had incorrectly administered ciprofloxacin. The Coroner found that, despite its catastrophic consequences, the intravenous administration of ciprofloxacin was a simple human error.

Following Ms Coleiro’s death, the hospital implemented a number of measures to ensure that such incidents do not occur in the future, including that nurses who are not trained in PICC lines are not to care for patients with a PICC nor access PICC lines for the purposes of medication, fluid administration or accessing bloods from the patient.

2. NFR orders

The Coroner held that it is often difficult to convey to families what an NFR order means, as each family member’s level of understanding can be very different. Therefore, it is very important that a family is fully informed and understands the reasons for the NFR order.

In Ms Coleiro’s case, the discussion with her family about the NFR was documented a number of times in the medical records. The notes described very clearly that a medical decision was made and CPR would not be initiated in the event of Ms Coleiro’s deterioration. What was unclear was whether the family understood the full implications of an NFR order.

3. NFR and iatrogenic events

The Coroner found that when it is known that an iatrogenic event has occurred, there is an expectation within hospitals that a code blue will be called so that medical staff can immediately assess the nature of the event and whether it can be treated. If the patient’s decline is found to be due to a reversible iatrogenic event, then an NFR order does not apply and CPR attempts can commence.

In Ms Coleiro’s case, the nursing staff did not realise that the iatrogenic event was the reason for her sudden decline. Therefore, the decision to not perform CPR was a medical decision made in good faith and in compliance with the NFR order.

4. Conclusion

The Coroner concluded that the NFR was appropriately imposed due to Ms Coleiro’s condition and comorbidities, and the incorrect administration of medicine was human error.

The Coroner was satisfied that the hospital had implemented measures to improve the administration of the relevant medicine and had demonstrated that had the hospital staff connected the iatrogenic event with Ms Coleiro’s decline, a code blue resuscitation would have taken precedence over the NFR.


The Coroner’s findings into Ms Coleiro’s death emphasise the importance of involving a patient’s family where a medical decision is made to impose an NFR order. In such circumstances, strong communication is the key to ensure that all involved understand the serious implications the order, with such clearly documented in the records It is also important to remember that where a patient’s deterioration is known or suspected to be due to an iatrogenic cause, an organisation’s policies should address whether a code blue should be called irrespective of the existence of an NFR.