Coroner's Finding: QR
Demographics
42y, female
Date of death
2021-09-18
Finding date
2024-04-17
Cause of death
Drowning due to combined drug (tramadol, venlafaxine, diazepam, quetiapine and cannabis) intoxication while scuba diving
AI-generated summary
A 42-year-old woman with bipolar disorder, chronic pain, and emphysema died by drowning while scuba diving in shallow water after a 3-year hiatus from diving. She was taking multiple CNS-depressant medications (tramadol, venlafaxine, diazepam, quetiapine) prescribed by her GP and psychiatrist, plus cannabis. Toxicology showed elevated levels of these drugs. The coroner found her medication regime was necessary and appropriate, and there was adequate communication between her prescribers. However, neither her GP nor psychiatrist had specifically discussed the risks of diving given her medications and lung disease, particularly as she resumed diving. The combination of drug effects, reduced diving experience, and excessive weights in her buoyancy vest likely contributed to loss of consciousness and inability to protect her airway. No criticism was made of her treating doctors.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Central nervous system depression from multiple medications
- Possible altered consciousness or panic state
- Lack of recent diving experience (3-year hiatus)
- Excessive weights in forward pockets of buoyancy compensator
- Emphysema and lung disease
- Possible serotonin toxicity from tramadol and venlafaxine combination
- Unfamiliarity with equipment after prolonged absence from diving
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