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A doctor failed to tick a box on a form during Patricia’s admission. It cost her life


An inquest into the death of Canberra nurse Patricia “Jill” Croxon has found medication was incorrectly administered to her after hospital staff failed to tick a box on a form when she was admitted in August 2019.

Croxon, 79, had been taking a combination of medications before she was admitted to hospital, but a coroner report has found that hospital staff did not tick a box indicating slow release of verapamil.

Verapamil is used to treat high blood pressure and to control chest pains. It works by relaxing the blood vessels in the heart to prevent it from pumping too hard.

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Since the box was not ticked to indicate a slow release of the drug, Croxon was given an immediate release dose, which led to heart problems.

“It was only after her admission to (Canberra Hospital), when there were changes in the form the medication was taken and the timing of administration of the drugs, that effects were produced that caused the cardiac arrest that took Mrs Croxon’s life,” Coroner Ken Archer said.

Her death was formally reported to the coroner as it was “a death that was ‘unnatural’ and had arisen in circumstances which were at that time unknown”.

The court heard that the doctor “frankly admitted” his failure to tick a box indicating the slow release of verapamil and did not “seek to rationalise, minimise, or explain away” his mistake.

An inquest made into the death of Canberra nurse Patricia “Jill” Croxon has found she was given the wrong medication when she was admitted into Canberra Hospital in August 2019. File image. Credit: LUKAS COCH/AAPIMAGE

“(The doctor) could not say if he was busy, distracted or rushed. It is likely that he was busy, and all those factors may have been at play,” Archer said.

The inquest, which included hearings conducted on November 21 and 22, 2022, confirmed suspicions that Croxon’s death was caused by irregularities in drugs administered to her.

Archer added that although the question of public safety arose from the inquest, he was satisfied the issues had already been addressed and that there were “changes that have occurred to drug prescription and administration practices at (the hospital) since Mrs Croxon’s death”.

The 79-year-old was taken to Canberra Hospital just after midnight on August 5, 2019 and diagnosed with community-acquired pneumonia.

Her progress was described to be within the “normal ranges” until her condition rapidly deteriorated on August 4, 2019 when she developed hypotension.

She also had other conditions such as hypertension, arthritis, tachycardia, and osteoporosis.

After standard treatments failed to raise her blood pressure, the Medical Emergency Team was called at 1.15pm.

Croxon told one of the nurses who attended the MET call that she had received “too many pills” that morning.

She was transferred to ICU about 2.05pm and suffered a cardiac arrest soon after. She was resuscitated, but a clinical assessment determined her prognosis to be poor.

She died in the presence of her family about 12.21am on August 5, 2019.

A life of service

Croxon was a registered nurse for 35 years and worked at the original Canberra Hospital in general practice, childcare, aged care and in drug and alcohol referral services for ACT Health.

Following retirement, she was said to have lived “an independent and social life and enjoyed spending time with her immediate and extended family and many beloved friends”.

Before her hospital admission, Croxon intended to celebrate her 80th birthday with family and friends and was also going to celebrate her 50th anniversary with her husband, Phillip Croxon.

Phillip died several months shortly after his wife’s death. They leave behind two children, Ben and Katie Croxon.

She was described by her children as a “caring, optimistic, and devoted mother, wife, and friend”.

“Mrs Croxon lived a full and productive life. She was loved by her family. She contributed much to the community through her work as a nurse and otherwise,” Archer said.

“Mrs Croxon lost her life in circumstances that should not have arisen.

“Although she was vulnerable because of her general health, she and her family might reasonably have anticipated that her treatment at (Canberra Hospital) would result in her being made well enough to be sent home in the loving care of her family.

“The picture of her last moments painted by her family in their statements and submissions will be forever etched in their memory.”

On behalf of the court, Archer expressed his condolences to Croxon’s family.

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Source: 7News