Failure to act promptly a factor in pills death

KAY BLUNDELL
Last updated 05:00 13/06/2014

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A 96-year-old woman in an Otaki rest home died from being given the wrong medications, a coroner has found.

Margaret Borgen died in Palmerston North Hospital on May 4 last year after being given another resident's medications in Ocean View Rest Home.

She was given some of her medication from a blister pack that morning by caregiver Helen Martin, who became distracted by another resident and returned about 8am to give Borgen the rest of her medication - but instead gave her anti-hypertension drugs.

Martin reported the error at 9.12am to the on-call registered nurse, who told her Borgen "should be OK", and to monitor her every 15 minutes.

The coroner's report found the failure to notify the doctor and seek medical advice was unacceptable.

Martin rang the nurse again at 9.59am and told her Borgen's condition had deteriorated - she collapsed when she wanted to use the commode in her room. The registered nurse, who was about half an hour away from the rest home, advised Martin to call the paramedics and Borgen's family.

She then told Martin to contact another registered nurse, Glennis Balloch, who lived nearby.

Balloch arrived straight away, put Borgen, who had roused a little and vomited, in the recovery position, and called Borgen's son and an ambulance about 10.45am.

It arrived about 11am and took Borgen to Palmerston North Hospital, where she died at 1.20pm with her family present.

The clinical director of the hospital's emergency department, Helen Cosgrove, said she could not categorically state that earlier intervention would definitely have saved Borgen's life, but there were successful treatments available that were denied her because of her late arrival.

"If she had attended the emergency department earlier, there would have been a significantly better chance of success."

An autopsy by forensic pathologist Katherine White found the cause of sudden death was the ingestion of cilazapril and diltiazem, anti-hypertension medications that were not prescribed for her.

Coroner Christopher Devonport said Borgen was badly let down by the actions of staff at Ocean View Rest Home. "Administering medications cilazapril and diltiazem, which were not prescribed to Borgen, caused her death.

"The actions of staff in failing to act promptly once the medication error was identified likely contributed to her death.

"Had there been more prompt notification by the caregiver to nursing staff of the medical error, immediate contact by nursing staff with a doctor, and more prompt summoning of ambulance, the chance of the lethal effect of the medication error being overcome would have increased significantly."

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The rest home would not comment.

- The Dominion Post

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