Deceased
Lesley Kaye Hasleby
Demographics
61y, female
Coroner
Chief Coroner Walker
Date of death
2011-09-13
Finding date
2018-12-20
Cause of death
respiratory failure consistent with end-stage chronic obstructive airways disorder
AI-generated summary
A 61-year-old woman with chronic obstructive airways disease, liver disease, depression, and alcohol dependence died from respiratory failure. Her general practitioner prescribed a contraindicated combination of central nervous system depressants (dothiepin and oxazepam) for years without adequate in-person review. Critically, blood tests in June 2011 showed worsening hypoxia, but the GP did not review the patient. In September, prescriptions were issued by telephone without assessment. The coroner found the care sub-optimal, noting that while the medication regime was inappropriate for her respiratory condition and a review opportunity was lost, causation was not established. Key learning: patients with deteriorating respiratory function on CNS depressants require mandatory face-to-face review, not telephone prescriptions, even if previously stable.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
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