UNCONTROLLED seizures suffered by a woman in a Vic aged care facility due to shortages of medication led to her death, according to a report from the State Coroner this week.
The patient, who had Alzheimer's disease and Down syndrome, had been prescribed 150mg twice daily of phenytoin suspension, but in Oct 2018 the medication began to run out at Homestead Lakes Residential Aged Care Facility in Geelong.
A 500ml bottle was requested from the local pharmacy, which advised that it was unavailable from its supplier for a week.
In the meantime the pharmacy attempted to contact the drug company to see whether tablets could be crushed for administration to the patient instead.
The following day a staff member from the aged care facility faxed the patient's GP practice warning that the pharmacy was unable to source the drug and asking the doctor to note any suitable alternative on the patient's electronic medication chart.
The Coroner noted that the fax did not indicate that the matter was urgent, meaning normal processes to escalate the issue were not followed.
It took a further two days before the GP attended the facility to provide a script for chewable phenytoin, but the patient had already missed two doses and no "loading dose" was prescribed.
The doctor noted that it was difficult to access the medication chart, because it could not be reviewed without the assistance of staff at the facility.
The following morning the patient was transported to hospital where she suffered a seizure leading to aspiration, respiratory distress and ultimately pneumonia which caused her demise a week later.
Coroner, Jacqui Hawkins, concluded that the sudden cessation of the medication increased the risk of seizures, in turn leading to a higher risk of aspiration pneumonia.
She recommended that the medicine management policy at the aged care centre be updated with advice on how to manage non/supply of medications from the pharmacy and the importance of communicating with the prescribing doctor about missed doses of essential medication.
See coronerscourt.vic.gov.au.
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