A judge is calling on Alberta Health Services (AHS) to improve how adverse drug reactions are communicated after an elderly woman died in a Calgary hospital despite her daughter’s repeated warnings about a Demerol intolerance.

Mildred Fahrner died in 2010 less than a day after she was admitted to the Rockyview General Hospital’s emergency department from a fall at home. She was 90-years-old.

A public inquiry report into her death was released Monday.

Fahrner's daughter, who has medical research background, was described as an “especially knowledgeable and articulate advocate for her mother.”

She was at her mother’s bedside during most of the hospital stay and repeatedly told staff her mother had a bad reaction to the drug Demerol, also called meperidine hydrochloride.

The report concluded that despite the daughter’s lobbying, Fahrner died because she was given “more meperidine than her body could tolerate.”

“She was in considerable pain. In hospital, the challenges were to identify the source of Mrs. Fahrner’s pain and to manage that pain. Unsuccessful efforts in the latter respect led to the use of meperidine.”

Provincial court judge Kenneth R. McLeod made several recommendations to AHS:

  • Considering steps and policies that would improve how patient and family requests about medications are recorded and acted upon.
  • Working with doctors to create standardized interpretations for medication orders.
  • A protocol requiring nurses to include precise information on the method of medication administration.
  • Raising awareness of the potentially adverse effects of narcotics, especially meperidine, in elderly patients.

McLeod concluded that all the nurses and doctors involved in the patient’s care were “clearly doing their best.”