“The Angel of Death” - Elderly woman dies after fatal dose of morphine administered by family friend.

Date of findings: 7 February 2017 Coroner: John Lock, Deputy State Coroner Inquest place: Brisbane Date of death: 16 July 2014

Factual Summary

ES (“Betty”) was aged 87 and had been suffering from heart disease, chronic kidney disease and emphysema. She was admitted to the Prince Charles Hospital on 29 June 2014 with increasing shortness of breath and was discharged on 10 July 2014 into the care of her family. After discharge her family requested a referral to a palliative care team.

Betty remained under the care of her daughter with the assistance of her GP, Dr SK.

On 16 July 2014 Betty passed away and her GP issued a cause of death certificate indicating heart failure. However, after an enrolled nurse (MB) was reported to have made comments about assisting in the death of a family friend and referring to herself as ‘the angel of death’ and ‘Dr Kevorkian’, Queensland Police Service (QPS) decided to investigate and inquest was undertaken.

Issues for Consideration

  • Whether the deceased and her family were provided appropriate end of life care support and services following her discharge from TPCH on 10 July 2014.

Evidence & Investigations

Cause of Death

  • Autopsy results: Autopsy revealed significant pre-existing natural disease but also morphine at levels within the range considered potentially fatal, fentanyl and Oxycodone. The cause of death was considered to be best described as “undetermined”.
  • The expert evidence of Dr McGuire, pharmacist and pharmacologist was that excessive morphine doses were a major contributing factor to Betty’s death and the presence of additional opioids would have added to the respiratory depressant effects.

Circumstances of Betty’s Death

Evidence of the daughter

  • Betty was not in a position to make any decisions regarding medications.
  • She (the daughter) was administering pain relief lollipops, fentanyl patches (which she thought were for her mother’s heart) and morphine.
  • On 16 July Betty’s breath was laboured and rattling. Betty started coughing and it sounded like she was choking. At around 9:30am green fluid came out of Betty’s mouth. The daughter called her friend, MB (an enrolled nurse) and requested her assistance.
  • She told MB she had administered morphine at 8:00am but was unsure how much her mother had taken in. She was very distressed and left the room. When she returned her mother was much calmer.
  • The daughter went to have a shower and when she returned her mother had passed away.

Evidence of MB

  • MB admitted she administered approximately 4ml of morphine and was aware that Betty’s daughter had administered a dose at 8:00am. She was also aware Betty was receiving OxyContin and observed a fentanyl patch on Betty (but after administration of the morphine).
  • MB acknowledged that she was not qualified to administer that type of medication without supervision.
  • MB said that her intention was to try and make Betty’s breathing less laboured.

Admissions made by MB to nursing staff

  • The inquest received statements from various nursing staff who over-heard conversations in which MB had indicated she had helped her friend die and that she was ‘the angel of death’.
  • MB did not deny those conversations occurred.

Was appropriate palliative care provided?

Evidence from the Prince Charles Hospital

  • The evidence was that Betty was improving and there were no signs that she would die soon. The goals of care at that point were focused on restorative, not palliative care.
  • There was a request to the palliative care service following a request from the family on the day after discharge.

Evidence of Dr SK

  • She was informed that Betty was at home after hospital admission but was agitated and not eating. Dr SK provided 20 fentanyl lozenges.
  • On 15 July 2014, the daughter called to advise that Betty wasn’t taking the lozenges. On the basis that Betty couldn’t eat, Dr SK prescribed liquid morphine.
  • Dr SK noted that Betty’s nursing home had returned all of the unused medications to her family when it was advised Betty wouldn’t be returning (including previously ceased medications). Dr SK stated she was completely unaware that those medications been provided to the family.

Evidence of Palliative Care Queensland, Dr Willian Syrmis

  • As it was accepted by the corner that the discharge process from TPCH was hurried because the family were keen to bring Betty home and that she was not in a state where she required urgent palliative care, Dr Syrmis was not critical of any delay in the provision of community palliative care services from Metro North HHS.
  • However, with the involvement of a palliative care service appropriate support could have been provided which may have reduced some of the distress caused and prevented administration of medication outside of that which was prescribed.

Queensland Policy Service (QPS) Investigations: Initial police investigations confirmed that MB was a close family friend of Betty and attended at her family’s home on the day of her death. However, it was determined that there was insufficient evidence to consider criminal charges.

Inquest Findings

  • The discharge process from TPCH was adequately performed in the restricted timeline given as a result of the family’s decision to bring Betty home as soon as possible.
  • The ideal situation would have been for the referral to palliative care to have occurred in the hospital and arrangements made at that time. However, this was not possible because of the rushed discharge.
  • The Post-Acute Care Team was given a referral and responded appropriately. It was unfortunate that the family did not avail themselves of the services on offer.
  • Medications were given to Betty by the family and by MB in a careless fashion which displayed ignorance as to the impact and effects on the medications being given.
  • It is quite clear that mixed drug toxicity, intentionally and likely ignorantly given was the predominant factor which brought about Betty’s death. However, it was provided in good faith and there was no intention on the part of the family or MB that Betty would die at that time.

Recommendations

  • MB was not registered as a nurse at the time of inquest. A copy of the decision was provided to APHRA and OHO.
  • The nursing home has made appropriate changes so that restricted drugs and ceased medications are not provided to the family.
  • The Coroner intended requesting the TGA consider clearer medication on Ordine (Morphine) medication.
  • Palliative Care Queensland made a number of recommendations. Although there were no issues with the care provided in this instance, the Coroner adopted those recommendations as best practice for future.

Chronology of Events

09.07.2014

Betty had a fall. A CT scan showed no head injuries.

The treating doctor spoke with the family, who wanted to take her home.
10.07.2014 Betty was discharged into the care of her family.
14.07.2014 Dr SK (GP) suggested the use of pain relief lollipops to Betty’s daughter and provided 20 for collection.
15.07.2014
AM Dr SK (GP) provided a written prescription for oral morphine due to concerns expressed by Betty’s family over the phone.
12PM First dose of morphine administered to Betty by her daughter. Provided approximately 4-hrly thereafter.
16.07.2014
Betty’s breathing was laboured and rattling.
8AM Dose of morphine provided by daughter to Betty
9AM (approx.) Green fluid came out of Betty’s mouth.
9:21AM (approx.) Betty’s daughter called her friend, MB (enrolled nurse).
9:30AM

MB arrived. MB applied an additional dose of morphine. Some of this drooled out.

The daughter became distressed and left the room
9:45AM (approx.)

The daughter returned to the room. Her mother appeared to be calmer. The daughter decided to take a shower.

MB gave Betty another dose of morphine (approx. 4ml – 5ml, possibly more)
10AM The daughter’s husband returned home. MB and the husband gave Betty a wash. During the course of doing so they realised Betty had died.