An elderly woman at Flinders Medical Centre died nine days after she was administered the wrong painkillers that were meant for another patient with a similar name in a neighbouring room, an inquest has heard. Janet Ann Cook, 79, was suffering severe medical issues when she was accidentally given hydromorphone at FMC on September 21, 2015. The painkiller was meant for Norma Cock in the room next door but a cascade of errors led to the mistake. Mrs Cook, who was already receiving palliative care for end-stage heart failure, was unconscious two hours later. She was rushed from the cardiac ward to intensive care but died nine days later. Opening the inquiry on Tuesday, counsel assisting Ahura Kalali said an expert report prepared for the coroner indicated that before the medication error, Mrs Cook potentially had weeks to live. “Mrs Cook still had time to live,” Mr Kalali told State Coroner Mark Johns. “Her life was materially shortened by this mistake.” Enrolled nurse Trafford Csorba was grilled for several hours before Mr Johns over his involvement in administering the drug. Mr Csorba was caring for both Mrs Cook and Ms Cock on the day of the accident. Ms Cock was scheduled to receive a tablet of hydromorphone and an intravenous injection of hydrocortisone at midday on September 21. Mr Csorba and registered nurse Michelle Bottger both got the tablet from the medicine room and went to bed 26, instead of bed 28, to administer the drug. Mr Csorba said he was too busy looking at medication forms to realise that Ms Bottger was administering the drug to the wrong patient. When he realised the mistake, Mr Csorba told Ms Bottger who opened the patient’s mouth and unsuccessfully tried to recover the tablet. Over the next hour and a half Mrs Cook’s vital signs dropped and she was rushed to intensive care. Mr Csorba was suspended the next day pending investigations by Flinders Medical Centre and the Australian Health Practitioners Regulation Agency. Mr Csorba told the court he had warned his supervisor at handover that morning that the patient’s names were similar and should be marked for special attention because mistaken identity was a possibility. He said the appropriate warning labels were not attached to the file or on the communal whiteboard specifying which patients were under the care of particular nurses. Ralph Bonig, acting for Ms Bottger, questioned Mr Csorba about his professional history which included disciplinary matters for failing to take observations and incorrectly administering medication. The inquest continues.
