Coronial
ACThome

Inquest into the death of [Redacted] Williams

Deceased

Ms [Redacted] Williams

Demographics

female

Coroner

Coroner Temby

Date of death

2023-04-27

Finding date

2026-03-10

Cause of death

sodium nitrite poisoning

AI-generated summary

A 70-year-old school teacher and community advocate with motor neuron disease (MND) died by sodium nitrite ingestion on 27 April 2023. She had explicitly expressed wishes to end her life and explored available options. Palliative care practitioners offered palliative sedation therapy (PST) at home, but conflicting medical advice about duration (2 weeks vs a few days) and eventual inability to provide home-based PST due to resource constraints left Ms Williams dissatisfied. She had sought voluntary assisted dying (VAD), which was unavailable in the ACT at that time. The coroner found no matters of public safety and no preventable errors. The case highlighted gaps in end-of-life options for terminally ill patients without access to VAD, leading to the ACT subsequently implementing a VAD scheme in November 2025. No clinical negligence was identified.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

palliative carepsychiatryneurology

Drugs involved

sodium nitritesedatives

Clinical conditions

motor neurone diseaseexistential distressintolerable suffering

Procedures

palliative sedation therapy

Contributing factors

  • motor neuron disease with rapid functional decline
  • unavailability of voluntary assisted dying in ACT at time of death
  • inability to provide palliative sedation therapy at home due to resource constraints
  • conflicting medical advice regarding expected duration of palliative sedation therapy
  • patient's desire for rapid death that palliative care could not guarantee

Coroner's recommendations

  1. CHH to consider developing a guide/policy for palliative sedation therapy in the community and at home
  2. ACT Policing to review welfare check policies to consider whether changes are desirable when medical professionals are involved, particularly where a medical practitioner has advised against a welfare check or indicated it may increase risk of harm
  3. Development of patient information materials on palliative sedation options (noted as consideration at CHH)
Full text

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