A woman who died in Canberra Hospital in 2021 had received massive doses of painkillers which an anaesthetist, in giving coronial evidence, believed was not appropriate for a woman her weight.
Coroner Ken Archer was told Sharyn Kaine weighed just 39kg when she was taken by ambulance to Calvary Hospital with symptoms of stomach pain and a distended and painful abdomen.
She was transferred to Canberra Hospital when, some 36 hours later, she had intestinal surgery.
The operation had appeared to have gone well.
But the problems began when Ms Kaine was transferred to the ward's post anaesthetic care unit and her anaesthetist requested the medications recorded on a handwritten sheet be transferred into a digital medication record, called the EMM.
The hearing was told of some confusion in this process, with the junior doctor responsible for transcribing the medications working an "after hours" shift.
The coroner noted some "tension" between the accounts provided by the senior doctor and the junior doctor in this process but he was unable to resolve it.
Transcription errors were noted, as was a failure to review patient dosages.
Heavy doses of paracetamol had been administered to the patient before and after her operation.
Meanwhile, Ms Kaine's condition deteriorated.
It was later found that she had mistakenly been given 1 gram of intravenous paracetamol - which was regarded as far too much for her weight - 13 times over five days.
Four days after surgery, Ms Kaine suffered a collapse and was rushed to intensive care. Liver failure due to potential paracetamol toxicity was identified.
A day later she was dead.
In assessing the post mortem report by chief pathologist Dr Johan DuFlou, Mr Archer said it was not possible to conclusively determine that paracetamol toxicity was responsible for Ms Kaine's death.
However, he did find that at the time of her death, the Canberra Hospital did not have any specific procedures or guidelines in respect of paracetamol administration.
"Processes ... were not sufficiently robust so as to compel a review of the doses being administered," he said.
He noted that in NSW hospitals, paracetamol was included in the list of high-risk medications, "due to the demonstrated and on-going risks of paracetamol overdose, particularly in the setting of IV (intravenous) administration".
"Guidance is given as to dosing levels, with reminders given to adjust dosage where patients are underweight," he noted.
Canberra Health Service told the court that the adoption of the Digital Health Record system "had rendered that [NSW] form of written guidance redundant".
However, as the coroner observed, "the potential for human error remains".
"For example, if an incorrect patient weight is input into the DHR, then the potential for paracetamol overdosing may remain. Sharyn's case also involved an input error, but in a (largely) pre-digital prescription and dosage monitoring environment," he said.
For transparency purposes, he recommended that Canberra Health Service publish statistical material "that identifies trends in adverse medication outcomes (including non-fatal outcomes) at [the hospital] since the introduction of the DHR, including adverse outcomes involving paracetamol".
