Health Alert (Australia) – December 7, 2015

In This Issue:

– Judgments; Legisltation; and Reports.

-Excerpt from Judgments:


30 November 2015 –

Inquest into the Death of Maria Dolores Coliero COR 2011/003564

This inquest related to a patient who had been administered medicine incorrectly and, as a result of having

executed a not for resuscitation order (“NFR”), was subsequently not resuscitated when this incorrect

administration of medicine led to her becoming unresponsive. It is hospital policy that a code blue to relieve

and assist the patient will always be called for an iatrogenic event such as the incorrect administering of

medicine. However, the error by nursing staff was not noticed immediately and not attributed to the

patient’s decline. As a result, a code blue was not called due to the NFR.

The conclusion of the coroner was that, in this case, the decision by hospital staff not to call a code blue and attempt to resuscitate the patient was made in good faith and with respect for the NFR in place. The NFR was appropriately imposed due to the patient’s condition and comorbidities, and the incorrect administration of medicine was simple human error. The hospital also established that measures had been put in place to improve the administration of this particular medicine and submitted that, had the hospital

staff connected the iatrogenic event with the decline of the patient, then code blue resuscitation this would have taken precedence over the NFR.

The coroner also commented that several members of the patient’s family apparently did not understand the implications of the NFR, but that the hospital staff had made an effort to communicate the medical reason for initiating the NFR, and documented these discussions.

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