An elderly woman who died after being given the wrong
medication at her rest-home was "badly let down'' by staff, a
coroner has found.
Coroner CJ Devonport found that Margaret Ellen Borgen, 96,
died after unknowingly taking medication from a "blister'' of
eight drugs meant for another resident at Ocean View Rest
Home in Otaki.
The drugs were given by caregiver Helen Martin, who started
her round at 8am on Saturday May 4, 2013 by handing out
The rest-home provided each resident's drugs in a blister
that is snapped off from a pack and dispensed by hand or in a
Ms Martin had started with Mrs Borgen, who took two
individual blisters, and gave her the first of her doses.
She then came back to the trolley and became distracted by a
resident who was new to the rest-home and became lost.
When Ms Martin returned to the trolley after assisting the
confused resident, she snapped another blister from another
pack, intended for a different resident, and gave it to Mrs
As Ms Martin moved on to the next patient she realised the
mistake. But she finished her round before calling the
on-call registered nurse Jane Western to tell her what
Ms Western told her to monitor Mrs Borgen every 15 minutes.
When Mrs Borgen then collapsed and vomited, Ms Martin phoned
Ms Western back asking her to come to rest-home.
Ms Western said she wouldn't come, and told the caregiver to
call another nurse who lived closer to the rest-home.
It wasn't until about two hours after Mrs Borgen had been
given the wrong medication that a registered nurse arrived at
An ambulance was called and Mrs Borgen was taken to
Palmerston North Hospital, where she died.
The coroner found she died from taking the Cilazapril and
Diltiazem, medication to lower blood pressure, that had not
Coroner Devonport said Mrs Borgen was "badly let down by the
actions of staff at Ocean View Rest Home.''
Staff's delay in getting medical treatment for Mrs Borgen
contributed to her death, the coroner said.
Doctors could have administered a medication that would have
counter-acted the Cilazapril and Diltiazem had Ms Martin had
alerted staff immediately.
"She was aware that the misadministration had occurred at
approximately 8am but failed to contact the registered nurse
on duty until 9:12am. That delay is unacceptable.''
Ms Western should have alerted doctors immediately, the
coroner said, and her failure not to was unacceptable.
- by Sophie Ryan