Lethal dose of morphine given to Sheila Thurlow a 'failure' of everyone involved, inquest hears
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 is now the subject of an inquest which is being held in Brisbane.
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.
"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."
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.
"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.
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."
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.
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 continues.
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