Finding into death of Kelly Elizabeth Hall
Deceased
Kelly Elizabeth Hall
Demographics
43y, female
Date of death
2013-05-16
Finding date
2016-04-22
Cause of death
mixed drug toxicity including methadone
AI-generated summary
43-year-old woman with long-standing opioid and benzodiazepine dependence died from mixed drug toxicity including methadone, amitriptyline, pregabalin, duloxetine, diazepam and paracetamol. Two GPs prescribed drugs without coordinating care: Dr L. prescribed methadone, benzodiazepines and duloxetine; Dr S. prescribed amitriptyline and pregabalin. Key failures included: lack of communication between practitioners despite mutual awareness; Dr L.'s departure from Drugs and Poisons Regulation guidelines in prescribing five takeaway methadone doses weekly despite known harmful alcohol and heroin use; long-term diazepam prescribing without adequate weaning despite guidelines recommending cessation; and failure to notify DPR of benzodiazepine prescribing. The combination of CNS depressants at prescribed doses proved fatal. Better coordination, adherence to existing guidelines, real-time prescription monitoring, and rescheduling all benzodiazepines would likely have prevented this preventable death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- lack of care coordination between two prescribing GPs
- departure from Drugs and Poisons Regulation guidelines for takeaway methadone dosing
- long-term benzodiazepine prescribing without adequate dose reduction
- failure to notify DPR of benzodiazepine prescribing
- drug interactions between CNS depressants
- polypharmacy in patient with history of drug dependence
- alcohol abuse
- heroin use
Coroner's recommendations
- Victorian Department of Health and Human Services to take national lead in immediately implementing Real Time Prescription Monitoring system in Victoria
- Within 12 months, Therapeutic Goods Administration to move all benzodiazepines into Schedule 8 of the Standard for the Uniform Scheduling of Medicines and Poisons
- Royal Australian College of General Practitioners to consider revision of standards and guidelines to provide best practice guidance on coordination of care between general practitioners at different clinics
Full text
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