Finding into death of Terri Anne Woolley-Peresso
Deceased
Terri Anne Woolley-Peresso
Demographics
44y, female
Date of death
2012-10-04
Finding date
2015-06-23
Cause of death
Unascertained
AI-generated summary
A 44-year-old woman with chronic pain, epilepsy, and opioid dependence died at home with an unascertained cause in the setting of prescription medication use. She was a known 'doctor shopper' who obtained opioids from multiple prescribers simultaneously. Two GPs prescribed strong opioids (hydromorphone, oxycodone) without holding required Schedule 8 permits and without consulting the Drugs and Poisons Regulation (DPR) Help Line, which would have revealed her history of drug-seeking behaviour and existing ORT prescriptions. An Addiction Medicine Unit had recently advised against opioid prescribing. Clinical lessons: GPs must contact DPR before prescribing Schedule 8 drugs to new patients, especially those with pain and potential drug dependence; the DPR Help Line provides superior information to the Prescription Shopping Information Service; complex chronic pain patients with substance use disorder should be referred to specialists; and doctors must understand their legal obligations regarding permit requirements.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Prescription medication use including diazepam, tramadol, and hydromorphone
- Possible polypharmacy toxicity
- History of drug-seeking behaviour and doctor shopping
- Medication stockpiling suggesting unpredictable tolerance levels
- Fatty liver disease with associated metabolic disturbances
- Inadequate GP assessment before prescribing opioids
Coroner's recommendations
- The Royal Australian College of General Practitioners should review the circumstances of Ms Woolley-Peresso's death and consider how to better educate doctors about the benefits of contacting state-based drugs and poisons regulators before prescribing potentially dangerous or addictive drugs.
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