INQUEST INTO THE DEATH OF SUELLEN EDITH DAVIS

Contributing factors

• Patient consumed over-the-counter medications (Dolased, Promethazine) without medical knowledge or supervision
• Multiple sedative medications combined causing significant respiratory depression and drowsiness
• Patient unable to extricate herself from flexed-neck position due to sedation
• Lack of systematic medication review documenting over-the-counter drug use
• Inadequate clarification by GP of which specific over-the-counter medications were appropriate when discussing pain management alternatives
• Increasing use of Dolased in the months prior to death not detected by treating doctors
• Patient becoming increasingly difficult to rouse from sleep prior to death
• Delayed and infrequent communication between GP and pain specialist regarding medication changes

Coroner's recommendations

1. Pain clinic should implement a completed questionnaire about all over-the-counter medications (including recreational drugs, herbs, vitamins and supplements) as part of initial patient assessment
2. General practitioners should conduct more proactive systematic medication reviews specifically documenting all over-the-counter medications being taken by patients on complex pain regimens
3. General practitioners should be more specific in discussions about over-the-counter pain medication use, documenting exactly which products are appropriate when advising patients to use OTC alternatives
4. Improved communication between pain specialists and general practitioners regarding medication changes and patient medication history to ensure consistent and complete medication records