Coroner's Finding: CE de-identified
Demographics
69y, male
Date of death
2020-06-22
Finding date
2023-05-25
Cause of death
amitriptyline and alcohol toxicity with ischaemic heart disease
AI-generated summary
A 69-year-old man with longstanding anxiety, depression, heavy alcohol use, and multiple prior intentional overdoses of amitriptyline died from combined amitriptyline and alcohol toxicity with underlying ischaemic heart disease. After a serious intentional overdose in May 2020 requiring ICU admission, hospital psychiatry directed cessation of amitriptyline. However, the prescribing GP received this discharge advice late and the patient obtained two repeat prescriptions from different pharmacies within 24 hours (100 tablets total), falsely claiming a lost prescription. The coroner found no fault with the pharmacist or GP individually but identified a critical system failure: hospital discharge summaries containing urgent medication cessation advice were not immediately communicated to GPs and pharmacies, enabling the patient to access a contraindicated medication that he fatally overdosed on.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- intentional overdose of amitriptyline
- heavy chronic alcohol use
- delayed communication of hospital discharge advice to GP
- lack of immediate notification system from hospital to pharmacies regarding medication cessation
- patient obtained two repeat prescriptions from different pharmacies within 24 hours
- patient's false statement to pharmacist about lost prescription
- failure to implement staged supply or repeat restriction on prescription
- underlying severe ischaemic heart disease
Coroner's recommendations
- Public hospitals in Tasmania should consider implementation of immediate notifications to a patient's general practitioner and to relevant dispensing pharmacies in circumstances where the patient's hospital discharge summary records urgent and critical information pertaining to cessation of, or changes to, a patient's prescription medication.
Full text
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