Coroner's Finding: WOOD Jacqueline Moyra
Deceased
Jacqueline Moyra Wood
Demographics
17y, female
Date of death
2002-06-09
Finding date
2008-01-02
Cause of death
raised intracranial pressure due to hepatic encephalopathy related cerebral oedema from fulminant liver failure secondary to paracetamol overdose
AI-generated summary
Jacqueline Wood, aged 17, died from hepatic encephalopathy-related cerebral oedema following fulminant liver failure caused by paracetamol overdose. She ingested approximately 90 paracetamol tablets on 3 June 2002 but did not disclose this during her first hospital admission for vomiting and suspected gastroenteritis. Early clinical presentation mimicked infectious gastroenteritis with seizure-like symptoms; paracetamol toxicity was not suspected without disclosure of ingestion. The coroner found the death resulted from overwhelming psychosocial pressures, particularly family coercion regarding allegations of sexual abuse she had made, combined with her intellectual disability, epilepsy history, and past trauma. No criticism was directed at healthcare workers; the death could not have been predicted despite available support structures. Key lesson: paracetamol overdose presents with non-specific gastrointestinal symptoms; active enquiry about deliberate self-harm or ingestion is essential in young people presenting with vomiting, and high index of suspicion warranted when liver function deteriorates unexpectedly.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- paracetamol ingestion not disclosed on first hospital admission
- initial presentation mimicked gastroenteritis and seizure disorder
- paracetamol levels not requested in absence of clinical suspicion
- psychosocial stress from sexual abuse allegations and family coercion to withdraw charges
- intellectual disability affecting decision-making capacity
- history of childhood sexual abuse and complex family relationships
- lack of predictability of suicidal intent despite available support
- free access and limited supervision in residential care setting relative to cognitive maturity
Coroner's recommendations
- Enhanced training for healthcare workers in recognising paracetamol overdose presentation with non-specific gastrointestinal symptoms
- Active enquiry about deliberate self-harm and substance ingestion in all young people presenting with vomiting
- Consider paracetamol levels in young people presenting with unexplained gastrointestinal symptoms or liver dysfunction
- Improved coordination between foster care providers and therapeutic services regarding information sharing about vulnerable young people
- Review of placement practices in foster care to balance supervision needs with developmental autonomy for adolescents with intellectual disability
- Recognition that threats of self-harm by young people in care must be conveyed to all involved healthcare professionals
- Consideration of the cumulative impact of psychosocial stressors (family conflict, legal proceedings, loss of guardianship, complex relationships) in vulnerable young people
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