15
Oct 2024
Woman Dies After Receiving 1,000 Times the Intended Morphine Dose at Brisbane Hospital
Published in News on October 15, 2024
![What was meant to be a routine procedure—a pain pump inserted into Sheila Thurlow's spine to deliver medication for pain relief—turned into a nightmare. Hours passed with no updates from the hospital, leaving her family worried. They soon discovered that the 85-year-old had been given 1,000 times the intended dose of morphine, a fatal mistake.
Her husband, Raymond, expressed his heartbreak, saying, "I miss her terribly. It came as a big shock." The tragic incident raises serious concerns about hospital safety and medical oversight.
In June 2022, Sheila Thurlow was admitted to Ramsay Health Care's North West Private Hospital (NWPH) in Brisbane due to severe pain caused by metastatic cancer. Her doctor suggested inserting a pain pump to improve her quality of life.
Although the family found it odd that the procedure was scheduled for a Saturday, when fewer staff would be available, they trusted the medical team's judgment. Early that morning, around 6:30 am, Sheila's husband, Raymond, dropped her off at the hospital, expecting to see her again shortly after the routine surgery.
"I left the hospital thinking this would all be over quickly; they wouldn't want me sitting around. But hours later, I called the hospital, and the doctor said the procedure did not go as planned," Raymond recalls
“We just couldn’t believe what was happening,” Raymond said, realizing the gravity of the situation. He hurried to the hospital and informed his children, Dominic, Theresa, and Maria, of his growing concerns.
Theresa, Raymond's eldest daughter, made every effort to reach the hospital, but her long journey from the Northern Territory prevented her from saying goodbye. “It was tragic for all of us,” Raymond reflected.
"We were with Sheila, holding her hand, and we just couldn't believe what was happening before our eyes," Raymond recalled. Hospital staff informed the family that if Sheila could make it until 10 pm that night, she would likely survive.
Despite being treated with naloxone, an overdose reversal drug, her condition continued to deteriorate. The following morning, the family received a call from the hospital, informing them that Sheila had passed away. "It's very difficult to understand how this all came about," Raymond expressed, grappling with the tragedy.
Sheila's autopsy report, reviewed by ABC, identified the cause of death as "morphine toxicity," noting that the level of morphine in her blood before her death was "within the lethal range." The report indicated that the pain pump was inserted "without any issues" and that 100 micrograms (mcg) of morphine was intended to be administered as a spinal block.
Nurse 'Googled the procedure' the night before. The ABC has obtained a submission to the Office of the Health Ombudsman (OHO) from the hospital in response to a complaint filed by the family. This submission acknowledges that the procedure had never been performed at the facility and that the nursing staff had not received any training in it. It revealed that "one of the nurses 'Googled' the procedure the evening before in order to familiarize themselves" with it.
The submission also stated that there were no written protocols or processes established for the procedure, and no formal "safety huddle" took place to outline the roles and expectations of the staff in the operating room. It highlighted that the surgery was scheduled for a Saturday, which meant that management and education staff—who would typically be available during weekdays—were not accessible to support staff unfamiliar with the procedure.
According to the document, a physician ordered the morphine from the hospital pharmacy a week before the procedure. He verbally indicated to the pharmacy that 80 mg of morphine was the standard dosage for the pump, and the pharmacist confirmed that 100 mg of morphine was available in 5 ml ampoules, as stated in the submission.
It was later determined that "a spinal anaesthetic and sedation would be a safer option than a general anaesthetic, due to [Sheila's] age and co-morbid condition." However, the submission states that "at no point prior to or during the procedure" was this change in plan communicated to the nursing staff.
The submission also indicated there was "confusion between the nursing staff and the medical practitioners regarding the dose of morphine in the syringe," which ultimately resulted in the incorrect dosage being administered. Additionally, it revealed that nursing staff signed out the same dosage of morphine for another patient who was scheduled to receive a pain pump that morning. When asked by the ABC if this second patient received the same dosage, a spokesperson for North West Private Hospital confirmed, "there was no second incident relating to another patient."
A spokesperson for North West Private Hospital expressed that their "thoughts remain with the family in relation to the death of their beloved family member, Sheila." They stated that they were "limited" in their ability "to respond to the majority of the matters raised" due to "privacy restrictions and legal, coronial, and other regulatory processes underway."
The spokesperson stated that the hospital had "carried out open disclosure with the family," shared details of "the incident investigation findings and recommendations," and "conveyed our sincere apology for the tragic outcome.”
For families seeking accommodation near hospitals, guides and resources are available to assist in finding suitable lodging options, ensuring that loved ones can be close by during difficult times.](https://c3eeedc15c0611d84c18-6d9497f165d09befa49b878e755ba3c4.ssl.cf4.rackcdn.com/photos/blogs/article-810-1728991334.jpg "Woman Dies After Receiving 1,000 Times the Intended Morphine Dose at Brisbane Hospital")
What was meant to be a routine procedure—a pain pump inserted into Sheila Thurlow's spine to deliver medication for pain relief—turned into a nightmare. Hours passed with no updates from the hospital, leaving her family worried. They soon discovered that the 85-year-old had been given 1,000 times the intended dose of morphine, a fatal mistake.
Her husband, Raymond, expressed his heartbreak, saying, "I miss her terribly. It came as a big shock." The tragic incident raises serious concerns about hospital safety and medical oversight.
In June 2022, Sheila Thurlow was admitted to Ramsay Health Care's North West Private Hospital (NWPH) in Brisbane due to severe pain caused by metastatic cancer. Her doctor suggested inserting a pain pump to improve her quality of life.
Although the family found it odd that the procedure was scheduled for a Saturday, when fewer staff would be available, they trusted the medical team's judgment. Early that morning, around 6:30 am, Sheila's husband, Raymond, dropped her off at the hospital, expecting to see her again shortly after the routine surgery.
"I left the hospital thinking this would all be over quickly; they wouldn't want me sitting around. But hours later, I called the hospital, and the doctor said the procedure did not go as planned," Raymond recalls
“We just couldn’t believe what was happening,” Raymond said, realizing the gravity of the situation. He hurried to the hospital and informed his children, Dominic, Theresa, and Maria, of his growing concerns.
Theresa, Raymond's eldest daughter, made every effort to reach the hospital, but her long journey from the Northern Territory prevented her from saying goodbye. “It was tragic for all of us,” Raymond reflected.
"We were with Sheila, holding her hand, and we just couldn't believe what was happening before our eyes," Raymond recalled. Hospital staff informed the family that if Sheila could make it until 10 pm that night, she would likely survive.
Despite being treated with naloxone, an overdose reversal drug, her condition continued to deteriorate. The following morning, the family received a call from the hospital, informing them that Sheila had passed away. "It's very difficult to understand how this all came about," Raymond expressed, grappling with the tragedy.
Sheila's autopsy report, reviewed by ABC, identified the cause of death as "morphine toxicity," noting that the level of morphine in her blood before her death was "within the lethal range." The report indicated that the pain pump was inserted "without any issues" and that 100 micrograms (mcg) of morphine was intended to be administered as a spinal block.
Nurse 'Googled the procedure' the night before. The ABC has obtained a submission to the Office of the Health Ombudsman (OHO) from the hospital in response to a complaint filed by the family. This submission acknowledges that the procedure had never been performed at the facility and that the nursing staff had not received any training in it. It revealed that "one of the nurses 'Googled' the procedure the evening before in order to familiarize themselves" with it.
The submission also stated that there were no written protocols or processes established for the procedure, and no formal "safety huddle" took place to outline the roles and expectations of the staff in the operating room. It highlighted that the surgery was scheduled for a Saturday, which meant that management and education staff—who would typically be available during weekdays—were not accessible to support staff unfamiliar with the procedure.
According to the document, a physician ordered the morphine from the hospital pharmacy a week before the procedure. He verbally indicated to the pharmacy that 80 mg of morphine was the standard dosage for the pump, and the pharmacist confirmed that 100 mg of morphine was available in 5 ml ampoules, as stated in the submission.
It was later determined that "a spinal anaesthetic and sedation would be a safer option than a general anaesthetic, due to [Sheila's] age and co-morbid condition." However, the submission states that "at no point prior to or during the procedure" was this change in plan communicated to the nursing staff.
The submission also indicated there was "confusion between the nursing staff and the medical practitioners regarding the dose of morphine in the syringe," which ultimately resulted in the incorrect dosage being administered. Additionally, it revealed that nursing staff signed out the same dosage of morphine for another patient who was scheduled to receive a pain pump that morning. When asked by the ABC if this second patient received the same dosage, a spokesperson for North West Private Hospital confirmed, "there was no second incident relating to another patient."
A spokesperson for North West Private Hospital expressed that their "thoughts remain with the family in relation to the death of their beloved family member, Sheila." They stated that they were "limited" in their ability "to respond to the majority of the matters raised" due to "privacy restrictions and legal, coronial, and other regulatory processes underway."
The spokesperson stated that the hospital had "carried out open disclosure with the family," shared details of "the incident investigation findings and recommendations," and "conveyed our sincere apology for the tragic outcome.”
For families seeking accommodation near hospitals, guides and resources are available to assist in finding suitable lodging options, ensuring that loved ones can be close by during difficult times.
![A Medicare bulk-billed urgent care clinic, established by the federal government to help reduce emergency department pressures, has unexpectedly closed in Bundaberg, Queensland, less than a year after opening. Located 400 kilometres north of Brisbane, this clinic was one of 75 launched across Australia since June 2023 to redirect non-life-threatening cases away from hospitals, allow emergency departments to focus on the most critical cases.
Since its opening in November last year, the Bundaberg Urgent Care Clinic (UCC) has provided care to hundreds of patients. However, it unexpectedly closed its doors on October 22, with plans to reopen a week later. A sign now indicates that it is "closed until further notice." This makes the Bundaberg UCC the only one of its kind in Australia to shut down.
Patient Sue Hackett expressed her surprise upon arriving at the clinic on Tuesday when she found it closed. “I looked on the website, and it actually showed it was open... I've come here assuming they're open,” Ms. Hackett said.
Julie Sturgess, chief executive of the region's public health network Country to Coast, told the ABC that she could not provide specific details regarding the reasons behind the abrupt closure of the Bundaberg Urgent Care Clinic. “There are ongoing negotiations with the provider of that service,” Ms. Sturgess stated.
In response to the closure, a free phone service called Connect2Care has been established, allowing callers to speak with a registered nurse for their urgent care needs. “If further care is required, such as seeing a GP, we can organize an appointment either with your regular GP or a phone or video consultation with an online GP through that service,” Ms. Sturgess explained.
Additionally, some GP practices in Bundaberg are extending their hours to accommodate extra appointments. The Bundaberg UCC was operated by the Indigenous Wellbeing Centre (IWC), a non-profit Aboriginal-controlled health organization that serves the entire community. The IWC has declined to comment on the closure.
Federal Health Minister Mark Butler informed the ABC that services at the Bundaberg Urgent Care Clinic are expected to resume shortly.
The Australian Medical Association Queensland (AMAQ) has expressed ongoing concerns regarding the viability of the federal government's urgent care clinic program. AMAQ President Nick Yim emphasized that these clinics often duplicate services already provided by GP clinics. “We believe the federal funding for these clinics would be better invested in existing general practices around the state,” Dr. Yim stated.
Sue Hackett shared that she was able to secure a same-day appointment at a GP clinic, but it would come at a cost. “I just want to go to a place where I can get sorted with my medical condition, plus I don’t have to pay,” she expressed, highlighting the challenges many face in accessing affordable healthcare.
Tim Spargo, the owner of the pharmacy located next to the Urgent Care Clinic, emphasized the critical role the clinic has played in the community. He noted that when travellers forgot their chronic condition medications or prescriptions, he could direct them to the UCC for assistance. “In the 11 months that it's been open, it has really served a vital purpose … it has taken that pressure off [emergency departments],” Mr. Spargo stated, expressing the urgent need for such services in the area.
"What's clear is that federal Labor is unable to deliver on their commitments, and the people of Bundaberg and the surrounding district, who desperately need additional services, have been let down," he said. "No matter who you talk to, whether it's the GPs themselves or others, they are just overrun with work, and what should be a godsend is now closed."
In response, Mr Butler reiterated that patients can still receive assistance through the phone line, which will "help ensure the Bundaberg community's urgent care needs continue to be met."
Meanwhile, newly elected Queensland Premier David Crisafulli has pledged an additional half a billion dollars to reduce ramping across the state to below 30 per cent over the next four years. Queensland Health data from April to June this year indicates that 44.7 per cent of patients were not transferred off ambulance stretchers within 30 minutes. This issue is particularly pressing for Bundaberg Hospital, which has been struggling with high demand and limited resources. Crisafulli also promised to recruit 34,200 additional health workers by 2032.](https://c3eeedc15c0611d84c18-6d9497f165d09befa49b878e755ba3c4.ssl.cf4.rackcdn.com/photos/blogs/article-832-1730723697.jpg "Bundaberg Urgent Care Clinic Closes Abruptly, Leaving Patients in Uncertainty")
