Inquest into the death of Tiesha Marie Derbyshire

Contributing factors

• Intentional overdose of propranolol (200 tablets)
• Access to large quantities of propranolol prescribed by multiple GPs
• Medication stockpiling behaviour
• Concurrent use of multiple psychotropic medications at therapeutic or elevated levels
• Failure to detect concealed medication on admission despite high documented suicide risk
• Communication gaps between GP prescribers and mental health services
• Patient's secretive and resourceful nature in obtaining medications
• Doctor-shopping across multiple GP practices to obtain medications

Coroner's recommendations

1. A copy of the findings be provided to the Deputy Secretary of Primary and Community Care Group, Australian Government Department of Health and Aged Care, to highlight to Primary Health Networks the need for system integration improvement and uptake of existing Medicare-funded case conferencing initiatives
2. The Chair of the Royal Australian College of GPs (Queensland) be provided with a copy of the findings to highlight availability of case conferencing capability to Fellows
3. The Office of the Chief Psychiatrist and Queensland Health be encouraged to take an active role in highlighting the availability of case conferencing initiative in statewide communications to services
4. Publication of findings in the public domain to educate providers about utilisation of quality improvement initiatives for GP-psychiatry coordination