Finding into death of Ellzbeth Rebecca Robins
Deceased
Ellzbeth Rebecca Robins
Demographics
1y, female
Date of death
2010-02-24
Finding date
2012-04-02
Cause of death
Oxycodone toxicity
AI-generated summary
Ellzbeth Rebecca Robins, a 1-year-old girl, died from Oxycodone toxicity after ingesting an 80mg Oxycontin tablet on 24 February 2010. Her father took Oxycontin for arthritis, stored in a bedroom drawer. A Piroxicam tablet fell on the kitchen floor; while her mother searched for a corresponding Oxycontin tablet, she did not find it. The child likely ingested the tablet later that day, mistaking it for food (biscuit pieces were found in the loungeroom). She was found unresponsive by 8:45pm. Clinical lessons include: secure storage of potent opioids is critical in homes with young children; once removed from storage, high-risk medications require constant supervision; parents with mobility limitations managing young children need additional safety planning; and healthcare providers should reinforce medication safety counselling proactively. The coroner found no evidence of neglect by parents.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Accidental ingestion of 80mg slow-release Oxycontin tablet
- Medication tablet fell onto kitchen floor
- Young child had unsupervised access to areas where medication may have been located
- Child mistook tablet for food (biscuit pieces)
- Parents' mobility limitations due to chronic conditions
- Tablet not stored in locked container
Coroner's recommendations
- Recommendation regarding safe storage of highly toxic medications in homes where children are present (locked cupboard storage suggested by healthcare provider)
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