Finding into death of Noela McGowan
Deceased
Noela McGowan
Demographics
66y, female
Coroner
Coroner John Olle
Date of death
2013-10-07
Finding date
2013
Cause of death
Complications following paracetamol overdose
AI-generated summary
A 66-year-old woman died from complications of paracetamol overdose after ingesting Mersyndol (codeine/paracetamol combination tablets). She had developed dependence on over-the-counter Mersyndol over approximately 8 years, using it for pain and sleep. Evidence indicated 'pharmacy shopping'—purchasing from multiple pharmacies to obtain larger quantities. Between June-September 2013, she obtained 760 tablets from one pharmacy alone. The coroner found no fault with emergency or hospital management, which appropriately treated fulminant liver failure. Key clinical lessons: pharmacists must verify therapeutic need before supplying Schedule 3 medicines, limit single packages unless exceptional circumstances exist, and be alert to pharmacy shopping. Real-time monitoring of OTC codeine sales and enhanced warning labels about paracetamol toxicity could prevent similar deaths.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Over-the-counter codeine combination analgesic (Mersyndol) dependence
- Pharmacy shopping—purchasing from multiple pharmacies
- Lack of real-time monitoring of OTC codeine sales across pharmacies
- Inadequate pharmacist assessment of therapeutic need for repeated purchases
- History of suicidal ideation and previous suicide attempts
- Mental health conditions including depression, anxiety, and panic disorder
Coroner's recommendations
- A new cautionary and advisory label should be included in the Australian Pharmaceutical Formulary warning about toxicities associated with excessive doses of paracetamol, to be used whenever paracetamol/codeine combination products are supplied or dispensed
- Implementation of real-time monitoring of dispensing of OTC codeine products to detect pharmacy shopping and enable pharmacists to prevent over-supply and direct customers to appropriate clinicians for codeine dependence
Full text
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