An anaesthetist who was present when an elderly woman was given an “outrageously high” dose of morphine at a Brisbane hospital by another doctor has told a coroner the deadly mistake was a “failure of everybody in that theatre”.
Sheila Thurlow died after being issued 1,000 times the intended level of morphine
In June 2022, Sheila Thurlow, who had metastatic cancer, underwent a procedure to insert a pain pump in her spine at the North West Private Hospital in Brisbane.
During the surgery, pain specialist and primary proceduralist Dr Navid Amirabadi administered a single dose of 100 milligrams of morphine to Ms Thurlow.
This amount was 1,000 times the intended dose of 100 micrograms, and she later died.
The circumstances surrounding the 85-year-old’s death are now the subject of an inquest which is being held in Brisbane.
‘Outrageously high’ dose of morphine
On Tuesday, Dr Richard Galluzzo, who was responsible for Ms Thurlow’s sedation, told the coroners court he recalled Dr Amirabadi discussing a morphine injection with one of the nurses in the theatre during the procedure.
“[The nurse] said ‘I have got some morphine drawn up, it’s 100 milligrams’,” he said.
The vial contained 100 milligrams of morphine — 1,000 times more than the intended dose of 100 micrograms. (Supplied: Coroners Court of Queensland)
“I just remember Dr Amirabadi saying, ‘That can’t be 100 milligrams, it must be 100 micrograms’.”
Dr Galluzzo told the court he heard the pair go back and forth about the differing unit again before Dr Amirabadi asked her for the syringe.
“It was definitely in her hand, handing over to him,” he said.
Dr Galluzzo told the court he did not intervene in that conversation because he believed the nurse was mistaken as 100 milligrams of morphine was an “outrageously high” dose.
“There’s often a mix-up between micrograms and milligrams,” he said.
“I’ve never seen 100 milligrams drawn up specifically in theatres in my whole career.
“I wasn’t aware that it was an error going on.”
An inquest into Ms Thurlow’s death is underway. (ABC News)
Following the procedure, and during the transfer of Ms Thurlow to the intensive care unit (ICU), Dr Galluzzo said he recalled the same nurse telling him the amount of morphine that had been administered, but he presumed she was still incorrect.
“I didn’t respond because I still thought it was 100 micrograms,” he said.
Dr Galluzzo told the court it was during his next surgery with a second patient when he became aware of Ms Thurlow’s declining condition.
Sheila Thurlow, pictured with her grandchildren. (Supplied)
“I said to one of the nursing staff, ‘Where’s that ampoule? Do you still have the ampoule that you drew up the morphine?’ They said yes,” he said.
“I found the cracked ampoule and I noted it was 100 milligrams of morphine.”
The court heard Dr Galluzzo immediately notified the ICU registrar to advise it was most likely a morphine overdose and Ms Thurlow would require an opioid reversal drug.
Confusion over dose
Under cross-examination by Dr Amirabadi’s lawyer, it was put to Dr Galluzzo he could not have heard such a conversation between his client and the nurse during the procedure because he was focused on other things.
“It definitely got my attention,” he said.
“I heard the conversation, I was peripheral … but I wasn’t involved in the conversation.”
Sheila Thurlow’s family believe her life was cut short. (Supplied)
When it was suggested the conversation did not occur at all and he was confusing it with discussions had later, he asserted it “definitely” happened.
“My clearest memory of the day was that conversation … and the volume in the syringe,” he said.
Dr Galluzzo said in hindsight “everybody should have said something” at that point to address the confusion about the dose, including himself.
“It was a failure of everybody in that theatre,” he said.
Sheila Thurlow’s death has left a void in her family that feels impossible to fill, her husband has said. (ABC News)
Overdose was ‘irrecoverable’, ICU doctor says
Dr Rodd Brockett, who was the intensive care specialist working at the hospital that day, also gave evidence on Tuesday.
The court heard that in a statement he made in 2022, he had described the overdose as a “terminal event”.
When asked this week what he meant by this, Dr Brockett told the court that it was “irrecoverable”.
He said when determining how to proceed with Ms Thurlow’s treatment in the ICU, he had taken her cancer prognosis into consideration.
Dr Brockett told the court Dr Amirabadi had said Ms Thurlow had “months to a year” to live.
“She was frail in terms of poor mobility and [had] a disease which would be progressive and relentless,” he said.
Dr Rodd Brockett told the inquest Ms Thurlow’s overdose was “irrecoverable”. (Supplied)
In his statement he had said that meant it was “not appropriate” to intubate her, and if the overdose could not be controlled with the reversal drug, she was “heading towards significant brain injury”.
Dr Brockett told the court while he could not recall the specific discussion, he believed he had explained this to Ms Thurlow’s husband.Â
“And, if she survived, then after that, a prolonged rehabilitation phase with significant brain damage along the lines of almost dementia-like state,” he said.
When asked if there were any other therapies, aside from non-invasive ventilation and IV fluids, which he could have provided to Ms Thurlow that would have led to a better outcome for her, Dr Brockett said “no”.
Earlier in the inquest, Dr Amirabadi gave evidence and denied a nurse handed him the syringe and told him it contained 100 milligrams, or that he corrected her about it being 100 micrograms.
Dr Amirabadi told the court another proceduralist, Dr Mohabbati, who had flown in to assist him that day, was the one who handed him an unlabelled syringe and instructed him to inject it.
Giving evidence to the court, Dr Mohabbati said he heard Dr Amirabadi ask a nurse for 100 micrograms of morphine and he also confirmed with the nurse that was the correct amount drawn up.
The inquest will continue on Wednesday.