Coronial
SAhome

Coroner's Finding: BRADY Mary

Deceased

Mary Brady

Demographics

64y, female

Date of death

2000-01-15

Finding date

2001-07-16

Cause of death

Haemorrhagic bronchopneumonia complicating doxepin overdosage

AI-generated summary

A 64-year-old woman died from doxepin overdose complicated by haemorrhagic bronchopneumonia. She had attempted suicide in April 1999 and was referred to a psychiatrist (Professor Schioldann) who prescribed sertraline. Her GP (Dr S.) subsequently prescribed doxepin in December 1999 without consulting the psychiatrist, despite knowing the patient was under specialist psychiatric care. The patient appeared well at her final psychiatrist review on 5 January 2000 with no suicidal ideation noted. The coroner found Dr S.'s failure to communicate with the specialist about additional psychotropic medication was inappropriate, as it prevented the psychiatrist from being aware of the patient's request for further medication, which may have had psychiatric significance. However, the coroner acknowledged suicide is unpredictable and it cannot be concluded the outcome would have differed.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

general practicepsychiatrypathologyforensic medicine

Error types

communicationmedication

Drugs involved

doxepinsertralinenitrazepamalcohol

Clinical conditions

reactive depressionsuicide by overdoseprevious suicide attempthypertensionosteoporosisinsomniahaemorrhagic bronchopneumonia

Contributing factors

  • Ingestion of doxepin (25 capsules, fatal level 0.97mg/L detected)
  • Ingestion of nitrazepam (multiple empty packets)
  • Failure of GP to consult psychiatrist before prescribing additional psychotropic medication
  • Lack of communication between GP and psychiatrist regarding patient's medication requests
  • Patient may have been stockpiling medications for some time
  • Alcohol consumption (0.090% detected)

Coroner's recommendations

  1. General Medical Practitioners be reminded that when a patient has been referred to a specialist, it is necessary to communicate clearly with that specialist before prescribing medication or providing other forms of treatment which may be relevant to treatment being provided by the specialist
  2. GPs should not assume the patient will provide the specialist with all relevant information, particularly where the patient is or may be suffering from a psychiatric illness
  3. Dr S. should review her clinical practices with these issues in mind
Full text

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.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.