Coroner's Finding: de-identified SH
Demographics
57y, female
Date of death
2023-06-28
Finding date
2025-12-11
Cause of death
aspiration of gastric contents caused by combined drug and alcohol toxicity resulting in respiratory depression
AI-generated summary
A 57-year-old woman with complex medical and mental health conditions died from aspiration of gastric contents caused by combined drug and alcohol toxicity. She had severe chronic pain following abdominal surgeries, opioid addiction managed with methadone, depression, and multiple psychiatric conditions. On the evening of her death, she consumed alcohol while taking prescribed medications including methadone, ibuprofen, and Panadol, and was found deceased the next morning. Post-mortem toxicology revealed blood alcohol of 0.15 g/100mL, methadone, and unprescribed alprazolam. The coroner identified that her GP prescribed four weekly methadone takeaway doses, contrary to guidelines recommending a maximum of two doses weekly. However, the coroner found no evidence she deliberately ended her life and concluded her GP was diligent in managing her complex needs, though the methadone takeaway dosing should have been more conservative.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- consumption of alcohol while taking multiple prescription medications including methadone
- methadone prescribed at four takeaway doses per week contrary to clinical guidelines
- presence of unprescribed benzodiazepine (alprazolam)
- severe chronic pain and mental health distress
- impaired consciousness from combined toxicity
- possible stockpiling of methadone takeaway doses
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