Deceased
Jennifer May Tilley
Demographics
58y, female
Date of death
2018-01-08
Finding date
2021-12-17
Cause of death
undetermined; possible mixed drug intoxication and/or adrenal insufficiency
AI-generated summary
Jennifer May Tilley, aged 58, died on 8 January 2018 with an undetermined cause, though mixed drug intoxication and adrenal insufficiency were potential contributors. She had complex medical conditions requiring chronic pethidine (opioid) therapy for gut pain management. Toxicology revealed toxic pethidine levels and additional CNS depressants (citalopram, nitrazepam) not prescribed to her, which when combined with other medications increased overdose and serotonin toxicity risk. The coroner found the prescribing regime itself appropriate given her limited medication options, but identified multiple breaches of the Poisons Act 1971 by her GP in maintaining required Schedule 8 authorities. The coroner recommended prescribers ensure current authorities, register with the DORA system, and actively monitor Schedule 8 dispensing data to prevent similar preventable regulatory failures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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