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Coroner's Finding: QD de-identified

Demographics

45y, female

Date of death

2021-10-01

Finding date

2023-07-24

Cause of death

combined drug (tapentadol, nortriptyline, venlafaxine, codeine, oxycodone, quetiapine, paracetamol) and alcohol intoxication

AI-generated summary

QD, a 45-year-old woman with significant comorbidities including obesity, obstructive sleep apnoea, COPD, depression, and substance abuse history, died from mixed drug and alcohol intoxication. Toxicology revealed toxic/fatal levels of tapentadol alongside nortriptyline, venlafaxine, codeine, oxycodone, quetiapine, and paracetamol with alcohol. The coroner classified the death as misadventure rather than suicide. Clinical lessons include: GPs prescribing high-risk opioids must conduct regular risk-benefit assessments and monitor for substance abuse; timely provision of urine drug screens and physical examinations is essential; the treating GP did not consistently respond to requests from the Pharmaceutical Services Branch for screening results. Enhanced monitoring protocols for patients on multiple CNS-depressant medications with documented substance abuse and suicidal ideation may have identified escalating risk.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

general practicepsychiatrytoxicologyforensic medicinepharmacy

Error types

delaysystem

Drugs involved

tapentadolnortriptylinevenlafaxinecodeineoxycodonequetiapineparacetamolalcohol

Clinical conditions

opioid toxicitymixed drug toxicityobstructive sleep apnoeachronic obstructive pulmonary diseasemorbid obesitycardiomegalydepressionchronic suicidal ideationalcohol use disordersubstance use disorder

Contributing factors

  • obstructive sleep apnoea
  • morbid obesity
  • cardiomegaly
  • chronic depression
  • history of alcohol abuse
  • history of illicit substance abuse
  • possible aspiration of gastric contents
  • inadequate monitoring by prescribing GP
  • untimely response to Pharmaceutical Services Branch requests for drug screens

Coroner's recommendations

  1. General practitioners should conduct regular risk-benefit assessments when prescribing high-risk effect-modulating medicines, including opioids.
  2. General practitioners should monitor for signs of substance use and abuse in patients on opioids.
  3. General practitioners must provide information requested by the Pharmaceutical Services Branch within a reasonable time.
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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

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