Jabberwocky
Frumious Bandersnatch
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- Nov 3, 1999
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Paul Lau loved to ski and was looking forward to getting back on the slopes when he checked into Sydney's Macquarie University Hospital for a routine knee operation.
But within ten hours the normally active and otherwise healthy 54-year-old would be dead, succumbing to a drug overdose; a fatal concoction of opioids and pain relief medication.
Anaesthetist Dr Orbison Kim had prescribed the deadly dosage, one which was meant for another patient who could tolerate higher levels.
The prescribing error going undetected throughout the day and into the night, with 15 opportunities to pick up the mistake missed.
Counsel assisting the coroner, Kirsten Edwards, said one such opportunity was when Dr Kim discovered the father-of-two had been administered a fentanyl patch.
"Dr Kim had not prescribed this and he thought someone else had," Ms Edwards told the inquest.
Ms Edwards said the inquest would consider how and why such a serious prescribing error was not detected.
"This case strikes fear into the heart of anyone going for routine surgery," Ms Edwards said.
"Many feel these sorts of deaths just shouldn't happen."
The inquest heard a number of lines of defence had failed that night in 2015.
Ms Edwards told those gathered at the Glebe Coroner's Court that there was evidence to suggest it was a busy night on the ward.
The inquest heard Macquarie University Hospital, which is privately run, has since conducted a number of internal hearings and investigations.
Two nurses had been subject to disciplinary action, and a formal review, prior to returning to their jobs.
A third nurse has since left the hospital.
"There will be no finding in the inquest of negligence," Ms Edwards said.
"Dr Kim is not on trial, all enter the profession to save lives.
"There had been a tremendous amount of cooperation and those involved in the care of Paul have accepted they made mistakes, sometimes very serious mistakes."
Mr Lau's son Johnathon spoke of the family's devastation outside of court.
"All these feelings are being resurfaced. It's not easy to get through," he said.
"It's quite hard, honestly. We've had a lot of issues in the family."
9NEWS understands they will be seeking compensation, a case which is due to be settled at a later date.
The inquest, before acting state coroner Magistrate Teresa O'Sullivan, is set down for four days.
Source: https://www.9news.com.au/national/2...pital-death-inquest-wrong-drugs-after-surgery
But within ten hours the normally active and otherwise healthy 54-year-old would be dead, succumbing to a drug overdose; a fatal concoction of opioids and pain relief medication.
Anaesthetist Dr Orbison Kim had prescribed the deadly dosage, one which was meant for another patient who could tolerate higher levels.
The prescribing error going undetected throughout the day and into the night, with 15 opportunities to pick up the mistake missed.
Counsel assisting the coroner, Kirsten Edwards, said one such opportunity was when Dr Kim discovered the father-of-two had been administered a fentanyl patch.
"Dr Kim had not prescribed this and he thought someone else had," Ms Edwards told the inquest.
Ms Edwards said the inquest would consider how and why such a serious prescribing error was not detected.
"This case strikes fear into the heart of anyone going for routine surgery," Ms Edwards said.
"Many feel these sorts of deaths just shouldn't happen."
The inquest heard a number of lines of defence had failed that night in 2015.
Ms Edwards told those gathered at the Glebe Coroner's Court that there was evidence to suggest it was a busy night on the ward.
The inquest heard Macquarie University Hospital, which is privately run, has since conducted a number of internal hearings and investigations.
Two nurses had been subject to disciplinary action, and a formal review, prior to returning to their jobs.
A third nurse has since left the hospital.
"There will be no finding in the inquest of negligence," Ms Edwards said.
"Dr Kim is not on trial, all enter the profession to save lives.
"There had been a tremendous amount of cooperation and those involved in the care of Paul have accepted they made mistakes, sometimes very serious mistakes."
Mr Lau's son Johnathon spoke of the family's devastation outside of court.
"All these feelings are being resurfaced. It's not easy to get through," he said.
"It's quite hard, honestly. We've had a lot of issues in the family."
9NEWS understands they will be seeking compensation, a case which is due to be settled at a later date.
The inquest, before acting state coroner Magistrate Teresa O'Sullivan, is set down for four days.
Source: https://www.9news.com.au/national/2...pital-death-inquest-wrong-drugs-after-surgery
