Finding into death of Caroline Courtenay Webster
Deceased
Caroline Courtenay Webster
Demographics
53y, female
Date of death
2012-04-18
Finding date
2014-06-27
Cause of death
Combined drug toxicity (propranolol and insulin)
AI-generated summary
A 53-year-old registered nurse with longstanding depression, anxiety and benzodiazepine dependency died from combined drug toxicity (propranolol and insulin) in what was determined to be an intentional overdose. Ms Webster engaged in systematic doctor-shopping from at least eight prescribers across four clinics to obtain benzodiazepines and sedatives (particularly zolpidem), while deceiving her treating doctors about her medication use. Despite comprehensive assessments by multiple psychiatrists and the CAT team who identified her clinical deterioration, dependency and impaired judgment, she did not meet involuntary Mental Health Act criteria. Clinicians communicated appropriately once aware of doctor-shopping, but the lack of real-time prescription monitoring delayed detection. She accessed lethal quantities of propranolol (600 tablets via repeats) and likely obtained actrapid insulin from her ICU workplace. No adverse findings were made against any treating practitioners.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Doctor-shopping from multiple prescribers without coordination
- Systematic deception about medication use and diagnoses
- Zolpidem (hypnotic) dependency and benzodiazepine abuse
- Lack of real-time prescription monitoring system
- Access to lethal quantities of propranolol (up to 600 tablets per script with repeats)
- Workplace access to insulin as an ICU-employed nurse
- Functional capacity to present well and conceal drug abuse between episodes of sedation
- Longstanding depression with previous suicide attempts
- Multiple recent psychosocial stressors including humiliation from nursing registration review
- Financial stress
- Difficulty accessing preferred treatments due to doctor-shopping detection
Coroner's recommendations
- TGA should issue an alert to prescribers to exercise caution when prescribing propranolol to patients at risk of self-harm, particularly by overdose
- If clinically appropriate, substitute a beta-blocker safer in overdose for propranolol in high-risk patients
- Scripts for propranolol should provide small quantities (e.g. 20-50 tablets with no repeats) for patients at risk of self-harm by overdose, rather than standard 100 tablets with up to five repeats (providing up to 600 tablets access at once)
- Implement a real-time prescription monitoring system to detect doctor-shopping practices and coordinate prescriber awareness (referenced from COR 2012 2254 - Kirk Ardern matter)
- Review insulin storage and access protocols in hospitals, particularly regarding access by healthcare workers who may be at personal risk
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