A coronial inquest in South Australia has heard devastating evidence about the death of an elderly man who was allegedly given another person’s prescription medication in a pharmacy dispensing error. The case highlights the serious consequences that can arise when medication management systems fail and raises important questions about pharmacy procedures, patient safety, and professional responsibility.
Elderly Man Dies After Medication Mix-Up
The Coroners Court is investigating the death of 82-year-old Pelayo Del Carmen Cortes Godoy, who died in Adelaide in May 2020 after taking medication that had been incorrectly labelled and dispensed through a Webster-pak system.
A Webster-pak is a dose administration aid commonly used by pharmacies to organise medications by date and time, particularly for elderly patients or those managing multiple prescriptions.
According to evidence presented to the Court, Mr Cortes was managing several medical conditions, including type 2 diabetes, high blood pressure and reflux, requiring multiple medications. Mr Cortes had limited vision and spoke limited English.
The Court heard that the Webster-pak was allegedly labelled with Mr Cortes’ name on the front and another patient’s name and list of medications on the back.
How the Pharmacy Error Was Discovered
Mr Cortes began taking the incorrectly supplied medication after his wife collected the Webster-paks from a Salisbury pharmacy in May 2020. The Court heard that the Webster-paks were prepared at a separate nearby pharmacy.
Several days later, he became unwell. A locum doctor attended his home and quickly identified discrepancies between the medication packs and the listed patient names.
An ambulance was called and Mr Cortes was admitted to Lyell McEwin Hospital before being transferred to intensive care.
A post-mortem examination later found the cause of death to be aspiration pneumonitis complicating cardiac arrest following an accidental polypharmacy overdose.
The coronial inquest is now examining whether pharmacy guidelines and procedures were followed.
Webstercare, the company that produces Webster-paks has told ABC News that they were not the supplier of Webster-paks to the pharmacies concerned at the time of the incident and not all Webster-paks are made by them.
Why Medication Errors Can Lead to Negligence Claims
Medication dispensing errors can have catastrophic consequences, particularly for elderly or vulnerable patients. In Australia, pharmacists and healthcare providers owe patients a duty of care to ensure medications are correctly dispensed and labelled.
Where failures in professional standards result in injury or death, there may be grounds for a medical negligence claim or professional negligence action.
Cases involving medication errors often examine issues such as:
- inadequate checking procedures;
- labelling failures; and
- the dispensing of incorrect mediation.
Coronial findings can also lead to broader recommendations aimed at improving patient safety systems and preventing similar incidents.
Commentary From Our Medical Negligence Team
The case highlights the devastating consequences that can arise from seemingly small dispensing errors within healthcare systems.
Patients place enormous trust in pharmacists and healthcare providers to ensure medications are dispensed safely and accurately, particularly elderly patients who may already be vulnerable due to language barriers, vision impairment, or complex medical conditions.
Cases involving medication errors often raise important questions about whether adequate checking systems, staff training and safety procedures were properly followed. Coronial inquests can also play an important role in identifying systemic failures and improving patient safety standards across the healthcare sector.
While no legal outcome can undo the loss experienced by a family, these investigations are critical for accountability and preventing similar tragedies from occurring in the future.
Healthcare providers are expected to take reasonable steps to ensure patients understand their treatment and receive medications safely.
Public Apology During Inquest
During the inquest, a lawyer representing a part owner of the pharmacies involved publicly apologised to the Cortes family for the apparent errors and acknowledged the grief caused by Mr Cortes’s death.
The inquest is continuing and will hear evidence from pharmacists, industry representatives and other witnesses regarding the pharmacy systems and procedures in place at the time.
What This Means for Patients and Families
Medication errors are not always minor mistakes. In serious cases, they can result in permanent injury or loss of life.
If you or a family member has suffered harm due to a medication dispensing error, it is important to seek legal advice promptly.
Medical negligence claims can help families obtain answers, accountability and compensation where appropriate.
Healthcare providers, including pharmacies, are expected to maintain strict professional standards to protect patient safety.
What This Means for Practitioners
This inquest serves as a reminder to pharmacies and healthcare professionals of the importance of:
- robust dispensing and checking systems;
- clear labelling protocols;
- effective communication with vulnerable patients;
- documenting quality assurance procedures; and
- maintaining compliance with professional guidelines.
Even a single administrative or dispensing error can have devastating consequences.
Source: ABC News reporting on the coronial inquest into the death of Pelayo Del Carmen Cortes Godoy.
DISCLAIMER
This article reflects the current law at the time of publication. It is intended for informational purposes only and does not constitute legal advice. The actual decisions in each case are summarised for general understanding. For specific legal guidance in relation to your situation, please consult with a qualified legal professional.