A woman died in hospital after a series of oversights led to the wrong medication being administered "in circumstances which should not have arisen", a coronial inquest has found.
Patricia "Jill" Croxon died at Canberra Hospital, aged 79, in August 2019. She had been admitted two days prior with pneumonia.
Her condition suddenly deteriorated the next day when she developed low blood pressure.
She soon went into cardiac arrest and later died in the presence of her family.
A hearing, held over two days in November last year, found her death was caused by irregularities in drugs given to her at the hospital.
In a decision published on Wednesday, Mr Archer agreed with autopsy findings that her death was a result of medication related cardiac arrest in a patient with pneumonia and a weak immune system.
Mrs Croxon had been a registered nurse for 35 years before retiring and had worked at Canberra Hospital, in general practice, childcare, aged care and in drug and alcohol referral services for ACT Health.
Prior to her admission to hospital, Mrs Croxon was planning to celebrate her 80th birthday and looking forward to her 50th wedding anniversary.
Mrs Croxon had been taking the medications propranolol and verapamil to treat heart problems at least six months before she was hospitalised.
Both drugs depress heart function and "when taken together serious, and sometimes fatal, additive cardiovascular events can occur", the decision states.
The coroner found while the woman was in hospital, changes in the form of her medication and the time it was taken caused the cardiac arrest which killed her.
The 79-year-old was first seen by Dr Justin Armellin, who charted her medication while training as an emergency medicine registrar.
While he correctly listed her medication and dosage, Dr Armellin did not tick a box to indicate the verapamil should be administered in slow release form, not immediate release.
Despite this, the coroner stated Dr Armellin was "a kind and caring doctor" and "I make no criticism of him".
Mrs Croxon was reviewed by multiple doctors and nurses before she was given the drug in the incorrect immediate release form.
Mr Archer found a combination of factors led to Mrs Croxon's death, including: "an unwell patient with a range of acute and long-term morbidities, a possibly inappropriate association of the two medications ... an administration of verapamil in immediate release form, and a delay in the administration of propranolol".
He found procedures in place surrounding the administration of medications at the time "failed to bring to light the error".
"It is understandable that medical staff overlooked the issue in light of Mrs Croxon's medication history, the complexity of her comorbidities, and the nature of her presenting illness," Mr Archer said.
While the coroner found public safety issues arose from the case, he was satisfied those issues had been addressed by recent changes to drug prescription and administration practices at the hospital.
This also included changes to the administration of the after-hours medication cupboard.
"Mrs Croxon lost her life in circumstances that should not have arisen," Mr Archer said.
"Although she was vulnerable because of her general health, she and her family might reasonably have anticipated that her treatment at [the hospital] would result in her being made well enough to be sent home in the loving care of her family."
