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RNZ News
02-07-2025
- Health
- RNZ News
Prescription confusion may have contributed to woman's death
Close-up of MORPHINE SULFATE 1 MG/ML VIAL Photo: David GABIS / 123RF A coroner says Health New Zealand should centralise medicine dispensing records after he found a mistake with a morphine prescription may have contributed to a Levin woman's death. Coroner Mark Wilton found 71-year-old Norma Collins' death, at her home in May 2022, was associated with chronic obstructive pulmonary disease (COPD), with a background of excessive morphine administration. He could not determine the exact cause of Collins' death because she was cremated before it was reported to the coroner, and no post-mortem or toxicological analysis was done. But he found a GP at Ōtaki Medical Centre inadvertently prescribed a higher strength and dosage for Collins, which the pharmacist did not know about - and could not alert crucial people to. Collins suffered from end stage COPD with type 2 respiratory failure, pulmonary hypertension and anxiety. In the lead-up to her death she was prescribed morphine at 1mg strength at a dose of 2.5 to 5ml every three hours as needed by doctors at the Arohanui Hospice. Her daughter, who was Collins' carer, administered the morphine. She was advised to contact Ōtaki Medical Centre for repeat prescriptions. She did this in late May, concerned the liquid morphine was running out. A GP at the practice - who was not Collins' usual doctor, nor the lead practitioner at the centre - prescribed a higher dosage of 50ml of liquid morphine, at a higher strength of 10mg, administered at 1mg amounts. The GP told the Health and Disability Commissioner he checked prescribing records and the Ministry of Health database for Collins' medication history, but could find no previous prescription for liquid morphine, only one for a slow-release 10mg morphine tablet. He said he had not had specific palliative care training. "He said that he was unaware that Collins had previously been prescribed liquid morphine of a different dose and concentration by a doctor at Arohanui Hospice," Wiltobn said. The prescription was sent to Berrys Tararua Pharmacy, which had not dispensed the first prescription for Collins. It did not have access to her dispensing records so did not advise her daughter of any change. Wilton's report found Collins' daughter administered the drug as she had been doing - noticing her mother was drowsy and sleeping for hours at a time. "Collins' daughter did not think this was unusual as her mother had slept for long periods of time previously." She was found dead in her bed the morning of 31 May. Wilton said Health NZ should centralise dispensing records and share dispensing information through the New Zealand Electronic Prescription Service, following a previous finding by Coroner Alexandra Cunninghame. The service allows communication between prescribers and pharmacists, including emailing prescriptions and notifications for medications that have not been dispensed. He said if Berrys Tararua Pharmacy had access to dispensing records, the pharmacist could have checked out the different prescription. "This would have allowed the pharmacist at [Berrys Tararua Pharmacy] the opportunity to alert Collins' daughter to the difference in strength and dosage, or to question the GP at [Ōtaki Medical Centre] about the difference." Health NZ told Wilton it was making progress towards centralising dispensing records, but ultimately depended on funding allocation. Wilton said the Health and Disability Commissioner made recommendations to both the Ōtaki Medical Centre and Berrys Tarurua Pharmacy for future changes, and that the commissioner was satisfied this had been met. Sign up for Ngā Pitopito Kōrero, a daily newsletter curated by our editors and delivered straight to your inbox every weekday.
RNZ News
22-06-2025
- Health
- RNZ News
Former Lake Alice nurse charged over ill-treatment of children dies aged 93
Dempsey Cockran in court in 2021. Photo: RNZ / Nate McKinnon The only staff member at the notorious Lake Alice child and adolescent unit to face prosecution over the horrors at the Rangitīkei institution in the 1970s has died. Dempsey Corkran, 93, died on Saturday 14 June, according to death notices that appeared in weekend newspapers. The notices said the Marton man "died at home surrounded by his family", and his family thanked Marton district nurses and the Arohanui Hospice in Palmerston North. A private service has been held. "His presence, guidance and wit will be missed by us all," the notices said. Appearing in court under his full names, John Richard James Corkran, the former unit charge nurse faced eight charges of ill-treating children by injecting them with the paralysing drug paraldehyde. He was due to face trial in Wellington in 2023, but in June that year the High Court granted a permanent stay due to his failing health . Corkran first appeared in court in late 2021, then aged 89, at the conclusion of a third police investigation into the Lake Alice unit. That investigation found there was also enough evidence to charge the unit's lead psychiatrist Dr Selwyn Leeks and one other staff member, but they were unfit for trial. Leeks died in early 2022 in Australia, aged 92. Previous police investigations in the 1970s and 2000s did not result in charges. Corkran faced - and pleaded not guilty to - eight charges of ill-treating children between 1974 and 1977, carrying maximum penalties of 10 years' jail. Court documents said Corkran injected the boys with drugs for reasons including them running away; calling him a bastard; "being smart"; and because a boy was "enjoying himself too much, laughing and having jokes with friends". When the prosecution was halted, survivors of the Lake Alice unit spoke about their disappointment that no one would ever face justice for what happened there - horrors the government now acknowledged amounted to torture. Corkran did not appear at his later court hearings, but was at his initial call in the Whanganui District Court. Outside he declined to comment to reporters, and his family grew angry as television cameras followed him along the street. Corkran worked at Lake Alice from 1960 as a psychiatric nurse, becoming a charge nurse in 1968 and then in the child and adolescent unit, which opened in 1972, from 1974. Sign up for Ngā Pitopito Kōrero , a daily newsletter curated by our editors and delivered straight to your inbox every weekday.
