Coronial
VIChospital

Finding into death of Donna Maria Mousely

Deceased

DONNA MARIA MOUSLEY

Demographics

46y, female

Coroner

Deputy State Coroner Iain West

Date of death

2010-11-12

Finding date

2012-06-08

Cause of death

Hypoxic brain injury due to combined drug toxicity

AI-generated summary

Donna Mousley, aged 46 years with long-standing panadeine forte and diazepam dependence, presented to an addiction medicine specialist seeking management. Dr C. prescribed methadone 40mg on 9 November 2010 after consultation. She commenced methadone despite having taken codeine earlier that day. On 11 November, after her third methadone dose (45mg), she became unresponsive with respiratory depression and was found in cardiac arrest. She suffered hypoxic brain injury and died. Toxicology revealed multiple drugs at low levels including methadone, diazepam, citalopram, and verapamil. The coroner found the death resulted from combined drug toxicity rather than methadone alone. Dr C.'s critical failure was not explicitly advising a 36-hour washout period after the final codeine dose before methadone commencement, increasing overdose risk. The coroner found no basis to criticise any health professional and did not make an AHPRA referral.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

addiction medicinegeneral practicepharmacyemergency medicineintensive care

Error types

communication

Drugs involved

methadonediazepamcitalopramverapamilparacetamol/codeinepromethazine

Clinical conditions

opioid dependencebenzodiazepine dependencerespiratory depressionhypoxic brain injurycardiac arrestdepressionanxietymigrainechronic obstructive pulmonary diseasecombined drug toxicity

Procedures

intubationcardiopulmonary resuscitation

Contributing factors

  • Methadone 45mg dosing on day 3 of initiation
  • Multiple concurrent medications at therapeutic levels (diazepam, citalopram, verapamil, promethazine)
  • Inadequate washout period after final codeine dose before methadone commencement
  • Lack of explicit written guidance about washout requirements
  • Initial high methadone dose (40mg) at upper limit of recommended range
  • Patient's underlying substance dependence history
Full text

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