Coroner's Finding: Brown, Sandra Anne
Deceased
Sandra Anne Brown
Demographics
54y, female
Date of death
2019-08-20
Finding date
2022-09-21
Cause of death
hypothermia, likely related to drug toxicity
AI-generated summary
Sandra Anne Brown, a 54-year-old woman with multiple chronic conditions including COPD, diabetes, bipolar disorder and epilepsy, died from hypothermia likely related to drug toxicity. She presented to the ED with breathing difficulties and COPD exacerbation but discharged herself against medical advice. She was found unresponsive at home two days later with a core temperature of 27.5°C. Autopsy revealed fluvoxamine at fatal range and amisulpride at toxic range. She had been socially isolated with inadequate community support despite declining functional capacity. Key clinical lessons: early recognition of medication toxicity risk in patients with polypharmacy and cognitive impairment; coordinated community care planning for vulnerable isolated patients; and appropriate escalation when patients with serious medical conditions self-discharge.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- fluvoxamine detected at fatal range in blood
- amisulpride detected at toxic range in blood
- elevated acetone levels suggesting metabolic acidosis
- self-discharge against medical advice from ED
- social isolation and lack of family/friend support
- inadequate community care coordination despite declining functional capacity
- polypharmacy with multiple sedating medications
- failure to access appropriate disability support services
- chronic medical conditions: COPD, diabetes, bipolar disorder, epilepsy
Full text
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