Incorrect dosage of enoxaparin likely contributed to the death of Warren James Newell at the Mersey Hospital in 2022

A ‘human error’ to administer an ‘inappropriate and excessive’ drug dosage likely led to the death of a former geotechnical engineer, a corner found. How it happened.

The Mersey Community Hospital. Patients were transferred from the North West Regional Hospital in Burnie to the Mersey Community Hospital in Latrobe. Picture: PATRICK GEE

“Human error” that saw a man given an “inappropriate and excessive” dose of a drug while admitted to the Mersey Community Hospital (MCH) at Latrobe likely led to his death, a coroner has found.

Warren James Newell died on October 1, 2022, from raised intracranial pressure caused by a left frontal-temporal-parietal subdural haemorrhage.

The 71-year-old former geotechnical engineer from Port Sorell was being treated for oesophageal cancer.

Before his death, Mr Newell’s chemotherapy had ceased and commenced on rivaroxaban — an oral anticoagulant medication used to treat and prevent blood clots.

On September 29, 2022, he attended the MCH complaining of chest, arm and neck pain — with an electrocardiogram indicating he had acute coronary syndrome.

His rivaroxaban medication was ceased, and aspirin and clopidogrel were commenced together with enoxaparin.

Mr Newell was administered 100g of enoxaparin twice daily.

Magistrate/Coroner Olivia McTaggart at the old railway roundabout in Hobart for a TasWeekend feature for International Women's Day. Picture: SAM ROSEWARNE.

On the afternoon of his death, Coroner Olivia McTaggart said he “became confused, disoriented and was trying to climb out of bed”.

“His consciousness was reduced, with his Glasgow Coma Score falling to 11/15,” Ms McTaggart said.

“His blood pressure had increased significantly, and his heart rate had dropped.

“An urgent CT scan of his brain showed a large left frontotemporal-parietal subdural haemorrhage with compression of his left lateral ventricle and midline shift to the right.”

It was determined that Mr Newell’s intracranial haemorrhage was “inoperable and unsurvivable”, and he died that evening.

In his affidavit, Ms McTaggart said Mr Newell’s son raised concerns about his father’s treatment in hospital.

However, she ruled that his treatment and diagnosis were appropriate for the most part.

But Ms McTaggart said hospital staff failed in one key area.

“The significant deficiency in treating Mr Newell was the administration to him of an excessive dose of enoxaparin — 100mg — on four occasions over two days before his subdural haemorrhage.”

It was determined that he should have been prescribed 70mg twice daily instead.

The Mersey Community Hospital. Patients were transferred from the North West Regional Hospital in Burnie to the Mersey Community Hospital in Latrobe. Picture: PATRICK GEE

Ms McTaggart said that “human error” caused Mr Newell to receive an incorrect dosage of enoxaparin.

“Upon the evidence, it is difficult to determine the extent to which the excessive doses of enoxaparin contributed to Mr Newell’s subdural haemorrhage.

“It is also difficult to determine whether he would have died of the same cause if the doses had been correct.

“There is no doubt that Mr Newell required the medication that he was given despite the possible consequences.

“However, it is likely that the inappropriate and excessive dose of enoxaparin played a role in his haemorrhage and death.”

Since Mr Newells’ death, Ms McTaggart said the Department of Health had implemented a range of measures, such as “including improved practices for recording a patient’s weight, placing correct enoxaparin dosages in guidelines, implementation of an e-prescribing system, a pharmacist service for the emergency department, and alleviation of workload in relevant circumstances”.