Finding into death of PC

Contributing factors

• excessive dothiepin dose (300mg daily, exceeding recommended maximum of 200mg)
• prolonged high-dose dothiepin treatment despite apparent inefficacy
• failure to review dothiepin treatment after psychiatrist expressed concern about overdose risk
• lack of dual diagnosis approach to comorbid mental illness and substance abuse
• failed psychiatric referral after breakdown of therapeutic relationship
• dispensing of large quantities (month's supply) of highly toxic medication
• possible prodrome of serious mental illness not identified
• unrecognized paranoid symptoms and early signs of psychosis
• inadequate coordination of care between GP and psychiatrist after relationship ended

Coroner's recommendations

1. Dual diagnosis approach should be implemented for patients with comorbid mental health and substance use disorders, utilizing specialist dual diagnosis services such as Western Hume Dual Diagnosis Service available in regional areas
2. High-dose dothiepin treatment should be reviewed when it becomes apparent the medication is not achieving therapeutic goals
3. When prescribing dothiepin to patients at suicide risk, careful consideration should be given to quantity dispensed at any one time
4. Coordination of care between general practitioners and psychiatrists should be formalized, particularly regarding cessation of psychiatric relationships and assumption of responsibility for complex medication regimens
5. More robust follow-up and alternative psychiatric access should be secured before high-dose toxic medications are continued indefinitely