Sharyn Kaine died at Canberra Hospital while receiving treatment there in 2021. Photo: Canberra Health Services.
The ACT Government has apologised for the “shortcomings” in care that resulted in the death of a much-loved grandmother.
The 73-year-old’s death was partly due to being given an overdose of the painkiller paracetamol in hospital.
In 2021, Sharyn Kaine’s condition stabilised after what was thought to be a successful surgery in Canberra Hospital. But she suddenly deteriorated a few days later and was found to be seriously unwell with signs of organ failure.
Ms Kaine died on 9 October 2021.
A 2024 inquest resulted in Coroner Ken Archer finding her death partially due to a paracetamol overdose that she received while being treated at the hospital.
The inquest also found a matter of public safety because, at the time of her death, the hospital did not have specific procedures or guidelines for paracetamol administration.
The hospital has since adopted the Digital Health Record (DHR).
Earlier this week, ACT Minister for Health Rachel Stephen-Smith tabled the government’s response to the inquest in the Legislative Assembly.
“CHS [Canberra Health Services] acknowledges and apologises for the shortcomings in Ms Kaine’s care and provides assurance that, through the implementation of the DHR, the health service has made significant improvements to medication safety,” she said.
“The ACT Government deeply regrets the deficiency in Ms Kaine’s care and apologises to her family and loved ones.”
Ms Stephen-Smith said Ms Kaine’s medication dosage was adjusted appropriately for her weight while in the care of CHS, but the systems and processes did not ensure the dosage reduction carried forward.
“This resulted in Ms Kaine being provided a standard adult dose of paracetamol, not the adjusted dose,” she said.
“The functionality now provided in the DHR significantly reduces the risk of administration of an inappropriate dosage, due to the settings in place within the medication management modules of the system.”
Rachel Stephen-Smith says the government apologises to Ms Kaine’s family . Photo: Michelle Kroll.
She said the DHR introduced electronic medication safety alerts to safeguard against errors such as the ones highlighted by Mr Archer.
“The DHR now provides automated dosage range checking and has a series of alerts to support clinician decision making,” she said.
Mr Archer had recommended CHS publish statistical material identifying trends in adverse medication outcomes at the hospital since the introduction of the DHR, including adverse outcomes involving paracetamol.
Ms Stephen-Smith said the government had accepted and implemented this recommendation.
The DHR has been used in all public health facilities since November 2022.
“DHR matches medication dosage against relevant considerations (such as weight) and patient requirements and has introduced hard stops and alerts in the system to support safe prescribing and medication administration,” Ms Stephen-Smith said.
“The CHS Annual Report will also include publication of the rate of serious adverse medication incidents (harm score 1 and 2 incidents).
“This includes non-fatal outcomes and will commence with CHS Annual Report 2024-25.”
