Coroner's Finding: TAYLOR Yutta

Contributing factors

• patient took both MAOI and SSRI in overdose despite warnings
• inadequate washout period between switching antidepressants
• pharmacist dispensed both incompatible drugs together
• GP switched antidepressant without consulting previous prescriber and without adequate warning
• locum doctor's misdiagnosis of UTI when patient presented with serotonin syndrome symptoms
• patient's history of cognitive impairment and medication non-compliance not communicated between doctors
• patient not admitted to hospital despite fever and distress
• doctor-shopper pattern not effectively managed across multiple practitioners

Coroner's recommendations

1. Pharmacy systems should flag when prescriptions for dangerous drug combinations are presented together, particularly when written by different prescribers
2. Pharmacists should contact prescribing doctors when potentially dangerous drug interactions are identified, rather than relying on assessment of patient mental state
3. Doctors switching antidepressant medications should consult with the previous prescriber about the reasons for the original choice
4. General practitioners should maintain awareness of and communicate patients' history of medication non-compliance and previous overdoses
5. When patients present with fever, sweating, agitation, and muscle symptoms, serotonin syndrome should be considered in differential diagnosis for those on serotonergic medications
6. Patients presenting with acute systemic symptoms should be encouraged to seek hospital admission rather than home management