Coroner's Finding: FERN Edmund James

Contributing factors

• polypharmacy with multiple interacting sedative medications
• elevated clozapine levels due to smoking cessation in July 1997
• heavy sedation from combination of clozapine, chloral hydrate, amitriptyline, benzodiazepines and post-operative analgesics
• recent septoplasty surgery with post-operative medications added to existing complex regimen
• lack of medication review and optimization
• inadequate discharge planning from hospital with no specific post-operative care instructions
• overlapping anticholinergic effects from multiple medications

Coroner's recommendations

1. The Medical Board of South Australia should take urgent steps to remind the medical profession about the dangers of polypharmacy, their responsibilities for monitoring and continual re-evaluation of prescribed medications, and the need to form independent judgment about the appropriateness of prescribing without relying solely on previous actions of other doctors
2. General practitioners in particular should be reminded that medications they prescribe may have additive and/or potentiating effects upon other medications the patient may be taking, and that certain medications may accumulate to toxic and lethal levels unless regular monitoring and re-evaluation is carried out
3. A copy of the findings should be forwarded to the Adverse Drug Reactions Advisory Committee of the Therapeutic Goods Administration