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

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.