Woman dies after aged care home failed to tell GP of missed medication doses

Coroner says faxes to the GP's practice never made the urgency of the situation clear
Woman dies after facility fails to tell GP she missed medication doses

A woman died of aspiration pneumonia following uncontrolled seizures after an aged care facility failed to inform her GP that she had missed doses of her regular anticonvulsant due to a medication shortage.

Annette Douglass, who had Down Syndrome and Alzheimer’s disease, had not experienced any seizures on her usual regimen of 150 mg twice daily of phenytoin suspension, a coroner’s court was told.

However problems began on 2 October 2018 when the medication began to run out.

Homestead Lakes Residential Aged Care Facility in Geelong, Victoria initially requested a 500ml bottle from a local pharmacy.