In June 2022, an egregious medical mistake at a Brisbane hospital resulted in the tragic loss of Sheila Thurlow’s life. She was 85 years old. Thurlow had surgery to install a pain pump in her spine. Unfortunately, this resulted in her being given a syringe containing 100 milligrams of morphine which was 1,000 times the desired dose of 100 micrograms. This overdose resulted in morphine toxicity during an emergent, but elective, postoperative procedure.
The tragedy led to a coronial inquest, which began on Monday. This important question makes clear the tragic problem of medication administration and oversight in acute medical environments. Sheila’s husband, Raymond Thurlow, portrayed his late wife as a loving and committed matriarch. He pointed out the profound emptiness her absence has left in their lives.
The Procedure and the Error
Dr. Navid Amirabadi, who was Sheila Thurlow’s primary proceduralist. He signed out 100mg of morphine from the narcotics locker. He was under the impression that it was supposed to be used to fill the pain pump rather than be injected directly into the spinal column. Afterward, a nurse handed him the syringe with the lethal dose and he administered it to Thurlow.
While defending the case, Dr. Amirabadi admitted liability for the improper preparation of the procedure and care of Sheila Thurlow. He stated, “He said this is your spinal … 100 micrograms … I asked how much I should give, and he said all of it.” This tragic miscommunication underscores just how crucially important it is to be crystal clear in every medical directive to avoid these types of heartbreaking outcomes.
Throughout the inquest Dr. Amirabadi stated he was profoundly sorry for what happened to Mr. Smith. I was already over the hump of the second operation. We figured out what occurred… and that step was deleted from the second procedure,” he continued. His comments show the regret and chaos, mission and morale that existed post-discovery of the error.
Family Struggles in the Aftermath
The circumstances surrounding Sheila Thurlow’s death, including the fact that she was disabled, have devastated her family, especially her spouse. Raymond Thurlow described Sheila as a loving mother and grandmother, noting that her kindness and generosity touched everyone she met. “Her kindness, generosity, hospitality and sparkling sense of humour touched everyone she met,” he said.
In a statement, Raymond Thurlow said that the trauma of dealing with the unexpected loss has been a difficult road. “I was in such a state after the tragedy. It took months to get myself together … it will probably be with me for the rest of my life,” he remarked. The emotional toll of losing Sheila has left him and their family grappling with grief, disbelief, and a profound sense of loss.
The family wishes that Sheila had come home with a different story after her procedure. They dreamed of seeing her finish her life as she had lived, on her own terms. “We hoped she would live out her years on her own terms,” Raymond expressed during the inquest.
Insights from Medical Professionals
Dr. Vahid Mohabbati, who mentored Dr. Amirabadi, was in the room for the procedure. He admitted that he called a nurse to get clearance on the proper morphine dosage for the spinal injection. He recalled the various vials he had seen — 10mg, 30mg and 100mg. When he faced the 100mg extreme dose, he was appalled. “100mg … I was shocked. I’ve never seen such a high concentration,” Dr. Mohabbati said.
He remarked on the potential implications of nursing errors in such situations, stating, “My initial recollection was it was a nursing error, but I leave that decision with [others].” This assertion brings to light the difficulty of holding a single personnel accountable when medical incidents are composed of multiple personnel.
This latest inquest hopes to determine exactly how Sheila Thurlow died. In addition to addressing critical equities and patient safety issues that arise with medication management in confusing healthcare settings, S. RES.
