An inquest into the death of Patricia 'Jill' Croxon, 79, at the Canberra Hospital in August 2019 has found she was given the wrong form of medication, causing her heart to slow down to catastrophic levels.
Mrs Croxon had been taken to hospital by her son, where she was diagnosed with pneumonia two days before her death.
Mrs Croxon, who had worked as a nurse for around 50 years, including at the old Canberra Hospital, had a number of chronic health conditions, including rheumatoid arthritis and heart irregularities.
She had been relying on a combination of medications prior to her hospital admission.
But an inquest into her death has found that hospital staff failed to tick a box to indicate her usual slow-release medication, leaving her with an immediate release form.
The inquest heard Mrs Croxon, having been a nurse, appeared to recognise that she was given a different dose of her medication, and reportedly told an attending Canberra Hospital nurse that she had had "too many pills".
The medication was Verapamil, which was designed to relax blood vessels and boost the supply of blood and oxygen to the heart while reducing its workload.
But, due to the hospital's error, Mrs Croxon erroneously ingested an immediate release dose and had to be transferred to intensive care, where she suffered a cardiac arrest.
Her family had the chance to say goodbye at her bedside but Mrs Croxon was heavily sedated and unresponsive at the time.
Family grieves woman who had upcoming milestones to celebrate
Mrs Croxon's family told the coroner that the "caring, optimistic, and devoted mother, wife, and friend" had been looking forward to celebrating her 80th birthday and 50th wedding anniversary.
"Mrs Croxon dedicated a large part of her life to caring for others through her career as a registered nurse," Coroner Archer said.
"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.
"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, I express my condolences to Mrs Croxon's family."
Hospital at fault, but no staff member to blame
Coroner Archer asserted that the failures in administering Mrs Croxon's medication presented a matter of public safety, but stopped short of making findings against individual hospital staff.
The court heard that the failure to tick a box indicating the slow release form of Verapamil was "frankly admitted" by Mrs Croxon's doctor, who did not "seek to rationalise, minimise, or explain away" the grave error.
"[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," Coroner Archer said.
He added that he was satisfied that the Canberra Hospital had made changes in the wake of the woman's "sudden and unnatural death".
The report noted that the hospital had introduced electronic record keeping that prompted staff to tick a box for slow or immediate release medication before any drugs could be prescribed.
Mrs Croxon's husband Phillip died several months after her death, leaving behind their children Ben and Katie.
