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.
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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
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
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
Dr S. should review her clinical practices with these issues in mind
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