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Smith, Rachel Danielle - Non-inquest findings

Deceased

Rachel Danielle Smith

Demographics

25y, female

Coroner

McDougall

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. Report an inaccuracy.

Specialties

general practiceneurologypsychiatrypathology

Error types

diagnosticsystemcommunication

Drugs involved

oxycodonecodeinetramadoldiazepamamitriptylinezolpidemparacetamolmorphineparacetamol/codeine

Clinical conditions

chronic migrainedepressiontype 2 diabetes mellitusobesityasthmachronic sinusitischronic cholecystitismixed drug toxicity

Procedures

cholecystectomy

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

  1. The Prescription Shopping Program should be alerted to the failure of their alert service in identifying Rachel Smith's excessive prescriptions
  2. 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
  3. Findings and medical records to be referred to the Office of the Health Ombudsman for review and appropriate action regarding the treating doctors' management
Full text
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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

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