FATALITY INQUIRY – Lucy Lecavalier – January 25, 2012 – Edmonton Provincial Court – Judge J.Henderson presidingHome > Blog > FATALITY INQUIRY – Lucy Lecavalier – January 25, 2012 – Edmonton Provincial Court – Judge J.Henderson presiding
A patient, who in 2008,was in a transition bed at a long term care
center waiting for palliative care was administered a lethal dose
of medication. She died within the hour.
LPN who was a float nurse, was informed patient required
pain medication. She looked for the assigned medication nurse, was
unable to find anyone, so she went to the medication room to prepare
the medication herself. In error, instead of selecting a 2 mgm. ampoule,
she chose a10 mgm ampoule of the more potent Hydromorphone
Hydrochloride/ Dilaudid from the box containing the 10 mgm. vials.
She broke the vial and withdrew the Dilaudid into a syringe. She was
intending to calculate the amount to be withdrawn when she was
interrupted by an aide who was looking for assistance. The LPN
capped the syringe, leaving the syringe & medication room unattended.
After some time she returned to med room, picked up the syringe &
failed to do further calculations. With fully loaded syringe, she went
straight to patient room & at 4:15 PM, administered the excessively
large fatal dose of potent narcotic.
Returning to the med room, she realized that she had massively
overdosed the patient. She immediately went to Care Manager
(who was not a nurse) to report her error. The Care Manager
called the Administrator.
911 was called. EMS arrived, were in pt. room by 4:35 PM. & told
by Norwood staff they could not attend patient until staff had cleaned
her up. Perhaps pt. bowels had already loosened. EMS over rode staff
& attended to pt, started an IV & oxygen. They found patient
to be unconscious, pulse threadlike, respirations depressed.
When ambulance removed patient from Norwood, arrived at RAH
hospital 4:55 PM, the patient was deceased.
When LPN was asked by the Court how she calculated the amount to be
administered, she responded that she did so in her head because
she had administered the medication the day before. Four years after
the incident, she still failed to understand that she was not dealing
with the 2 mgm. Dilaudid but with the much more potent Dilaudid
contained in the 10 mgm. vial.
– wrong medication
– wrong calculation