A 50-year-old woman with complex mental illness including depression, anxiety, and borderline personality disorder died from cyanide toxicity after ingesting potassium cyanide obtained from Sigma-Aldrich. She made four attempts to purchase cyanide, three of which succeeded. She fraudulently represented herself as being affiliated with Macquarie University to bypass regulatory controls. An independent psychiatrist confirmed her mental health care was generally appropriate and of high standard. The coroner found no act or omission by another person directly caused or contributed to her death, and concluded the manner of death was accidental drug overdose, noting she may have intended self-harm rather than completed suicide. Both Sigma-Aldrich and the NSW Pharmaceutical Services Unit implemented substantial procedural improvements post-incident.
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