Deceased
Deborah Margaret Ricklefs
Demographics
29y, female
Coroner
Coroner Audrey Jamieson
Date of death
2007-02-06
Finding date
2010-03-15
Cause of death
Invasive aspergillosis
AI-generated summary
A 29-year-old registered nurse with systemic lupus erythematosus (SLE) died from invasive aspergillosis. Dr G. prescribed lamotrigine 100 mg daily (double the recommended initial dose of 50 mg) on first consultation without proper review of prescribing guidelines or assessment of concomitant medication (epilem). The excessive dose triggered hypersensitivity syndrome, requiring steroid treatment that caused immunosuppression. Steroid-induced immunosuppression increased susceptibility to aspergillosis, though multiple intervening factors prevented establishing a definitive causal link between lamotrigine prescribing and death. Key clinical lessons: always verify dosing guidelines before prescribing unfamiliar medications, especially in complex patients; confirm concurrent medications despite patient reporting; maintain contemporaneous documentation; and recognise steroid immunosuppression risks in vulnerable patients.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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31y · Male·mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen)
A 31-year-old man subject to a post-sentence supervision order died from mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen) at a residential facility. He was a vulnerable person with acquired …
30y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest of unknown aetiolog…
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