Coroner's Finding: Tilley, Jennifer May
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.
Error types
Drugs involved
Contributing factors
- toxic level of pethidine detected on toxicology
- presence of unprescribed CNS depressants (citalopram, nitrazepam) in blood
- polypharmacy with multiple CNS depressants (temazepam, oxazepam, sumatriptan)
- adrenal insufficiency identified at autopsy
- long-term pethidine tolerance requiring escalating doses
- patient self-administration of pethidine with history of inappropriate use and medication misuse
- multiple breaches of Poisons Act 1971 in Schedule 8 prescribing authorities
Coroner's recommendations
- Prescribers of Schedule 8 substances should ensure they are in possession of current authorities from the Pharmaceutical Services Branch in respect of their patients
- Prescribers should be registered to DORA (Drugs and Poisons Information System Online Remote Access) and have working knowledge of its use
- Prescribers should access DORA when needed to enhance safe prescribing practices and monitor Schedule 8 dispensing data
Full text
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