Smith, Rachel Danielle - Non-inquest findings
Deceased
Rachel Danielle Smith
Demographics
25y, female
Date of death
2008-12-28
Finding date
2014-11-26
Cause of death
mixed drug toxicity
AI-generated summary
Rachel Smith, a 25-year-old woman with chronic migraines and depression, died from mixed drug toxicity after consuming multiple prescription medications including oxycodone, codeine, tramadol, diazepam, amitriptyline and zolpidem. She was a 'doctor-shopper' who obtained prescriptions from multiple practitioners without their knowledge of her concurrent consultations. Key clinical failures included: doctors failing to recognise she was taking far more medication than reported; absence of coordinated pain management or specialist review; inadequate use of the Prescription Shopping Information Service alerts; and lack of secure medication storage at home. The coroner found that earlier identification of her excessive medication use, coordinated prescribing practices, and a real-time pharmacy dispensing system could have prevented this death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Prescription drug-seeking behaviour from multiple doctors
- Failure of treating doctors to recognise excessive medication use
- Lack of coordinated prescribing between multiple practitioners
- Inadequate use of Prescription Shopping Program Alert Service
- Absence of pain specialist involvement
- Inadequate medication storage and control at home
- Patient deception regarding medication compliance and travel plans
- Delayed Prescription Shopping Program alerts (six-week lag time)
Coroner's recommendations
- The Prescription Shopping Program should be alerted to the failure of their alert service in identifying Rachel Smith's excessive prescriptions
- A national computerised pharmacy system should be instituted which automatically registers prescriptions as soon as they are dispensed, eliminating the six-week time gap in Prescription Shopping Program notifications
- Findings and medical records to be referred to the Office of the Health Ombudsman for review and appropriate action regarding the treating doctors' management
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