Man dies after ingesting incorrectly labelled medication in Adelaide

An 82-year-old man died after he ingested incorrectly labelled prescription medication dispensed at a pharmacy in Adelaide's northern suburbs, a court has heard.

A coronial inquest is investigating the circumstances that led to the death of Pelayo Del Carmen Cortes Godoy on May 21, 2020.

Counsel assisting the coroner Greg Dudzinski told the Coroners Court that Mr Cortes died after he took another person's medication provided to him in a Webster-pak at Chemist Warehouse Parabanks in Salisbury.

A Webster-pak is a large blister pack that pharmacists use to sort different medications into a single package, organised by dose and time.

Mr Cortes had limited vision and was taking seven different medications weekly for conditions including type 2 diabetes, high blood pressure and reflux.

He was born in Chile and moved to Adelaide in 1986. His two children often acted as interpreters for him and his wife, as they spoke limited English.

The court heard that on May 15, 2020, Mrs Cortes and another person picked up Mr Cortes's medication at Chemist Warehouse.

"Unbeknownst to Mr and Mrs Cortes, one of the Webster-paks that was provided to Mrs Cortes on the understanding it was for her husband had Mr Cortes's details on the front where the medication is visible, including his name and address on what I will refer to as a summary label," Mr Dudzinski told the court.

"This DAA [dose administration aid] contained medications prescribed to [the other person], not to Mr Cortes.

"The second pack had [the other person's] name and address on the front on the summary label, however the back had Mr Cortes's details, and this pack contained Mr Cortes's medication."

'Public apology' to family members

The court heard the Webster-paks were packed and labelled at a separate pharmacy in Salisbury, owned by the same proprietor as the one at the Parabanks Shopping Centre.

Three days later, Mrs Cortes opened the first Webster-pak and started administering what she thought was her husband's medication as prescribed.

On the afternoon of May 19, 2020, Mr Cortes began complaining something was wrong and his son arranged for a locum GP to attend that night.

The court heard when the doctor asked what medication Mr Cortes was on, he was handed the two Webster-paks.

"He quickly noticed the two Webster-paks had different medication and different names," Mr Dudzinski told the court.

An ambulance was called and the 82-year-old was taken to the Lyell McEwin Hospital.

Mr Cortes was transferred to the intensive care unit, but his condition declined in the early hours of May 21, 2020, and he died just before 6am.

A post-mortem examination concluded his cause of death was aspiration pneumonitis complicating cardiac arrest, following accidental polypharmacy overdose.

A coronial inquest underway is looking at whether the pharmacies that packed and dispensed the medications adhered to guidelines, procedures and policies.

On Tuesday, the lawyer representing the part owner of the pharmacies involved, Eric Cheng, told the court he apologised to Mr Cortes's family.

Deputy state coroner Emma Roper will hear evidence from witnesses, including the pharmacists who packed and dispensed the medication, the Pharmaceutical Society of Australia and the part owner of the pharmacy.

The inquest continues.