Coroner's Finding: KILEY Carol Anne
Deceased
Carol Anne Kiley
Demographics
55y, female
Date of death
2003-09-07
Finding date
2006-05-05
Cause of death
Multiple drug toxicity due to combination of alcohol and benzodiazepines (oxazepam at toxic level and temazepam at high therapeutic level)
AI-generated summary
Carol Anne Kiley, a 55-year-old woman with chronic back pain, depression, and likely alcohol dependence, died from multiple drug toxicity involving alcohol, oxazepam (toxic level), temazepam, and promethazine. Her GP, Dr B., prescribed these medications weekly for seven years without in-person clinical review, despite signs of poly-substance dependence and previous alcohol withdrawal seizure. The coroner found Dr B.'s management inadequate: indefinite benzodiazepine prescriptions without periodic assessments, failure to arrange psychiatric referral despite knowing her psychiatric history, and inadequate clinical notes. A critical delay in seeking help—the deceased likely collapsed in the early morning but was not found until 3 pm—may have been preventable had the live-in registered nurse properly recognized the emergency. The case illustrates risks of enabling benzodiazepine-alcohol dependence through loose prescribing practices without engagement of drug and alcohol services or meaningful psychiatric oversight.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Long-term prescribing of benzodiazepines and codeine without periodic clinical review
- Concurrent alcohol use with prescribed benzodiazepines
- Poly-substance dependence (benzodiazepines, codeine, alcohol)
- Lack of psychiatric referral or drug and alcohol service involvement
- Inadequate assessment of mental health and substance use
- Delay in emergency response—collapsed patient not discovered until several hours later
- Poor medical record-keeping
- Failure to monitor liver function or substance use adequately
- Reluctance of patient to engage with healthcare; GP accepted this without condition
Coroner's recommendations
- Findings to be brought to the attention of the Medical Board of South Australia
- Copy of findings to be brought to the attention of the Commissioner of Police
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