AN aged care nursing home made a serious misjudgement when it allowed a graduate nurse to be in charge of 36 high-needs patients in 2010, a coroner has found.
Coroner Rod Chandler made the comments in his finding that the nurse Julie Lord had not contributed to the death of a 67-year-old patient Stanley Whiley despite administering a dose of morphine 10 times what she intended.
A coronial inquest heard that Ms Lord was on her first shift at the Tamar Park nursing home at Legana.
"(Facility manager) Sandra Renshaw made a serious misjudgement in appointing Ms Lord as the sole nurse on duty for the afternoon shift of 6 March," he said.
"It was a decision which unfairly exposed Ms Lord and the residents to very real risk."
Mr Chandler said that Mr Whiley was critically ill with heart disease and had suffered two strokes when he received a dose of 25mg instead of the prescribed 2.5mg of morphine.
"I cannot be satisfied to the requisite degree that the morphine administered by Ms Lord on March 6 was a factor which caused or contributed to Mr Whiley's death," he said.
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