Inquest into the death of Lesley Kaye Hasleby
Deceased
Lesley Kaye Hasleby
Demographics
61y, female
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.
Error types
Contributing factors
- prescription of contraindicated CNS depressant medications (dothiepin and oxazepam) for prolonged period
- failure to review patient after blood tests showed worsening hypoxia in June 2011
- telephone prescription issued without in-person review on 12 September 2011
- inadequate clinical monitoring and assessment over years (no regular oxygen saturation or chest examination documented)
- patient reluctance to engage with medical advice compounded by domestic partner's discouraging influence
- social situation and squalid living conditions
Coroner's recommendations
- A copy of the findings be conveyed to Dr C. and the Royal Australian College of General Practitioners
- The Royal Australian College of General Practitioners may wish to provide guidance to its members on appropriate parameters for renewing prescriptions for patients without a face-to-face review, particularly when in possession of evidence of decline in their health status
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