Finding into death of Finding Ms RF
Deceased
Ms RF
Demographics
50y, female
Date of death
2013-09-17
Finding date
2017-06-20
Cause of death
Potentially fatal multiple drug toxicity (oxycodone, mirtazapine, citalopram, clonazepam, pregabalin) in a woman with epilepsy
AI-generated summary
Ms RF, a 50-year-old woman with epilepsy and chronic pain from a workplace wrist injury, died from potentially fatal multiple drug toxicity involving oxycodone, mirtazapine, citalopram, clonazepam, and pregabalin. She engaged in prescription shopping across six medical practices and six pharmacies, consulting 21 different GPs between January and September 2013. In September alone, she was prescribed 180 codeine/paracetamol tablets, 112 pregabalin, and 96 oxycodone tablets—approximately three times recommended monthly doses. Individual clinicians had sound clinical bases for their prescriptions given her documented pain history, but lacked visibility of her shopping across providers. The coroner found no individual prescriber at fault but highlighted the absence of real-time prescription monitoring as a critical system gap enabling preventable polypharmacy deaths.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Prescription shopping across multiple medical practices and pharmacies
- Lack of real-time prescription monitoring system
- Absence of coordinated medical records across prescribers
- Accumulation of central nervous system depressant medications
- Chronic pain requiring multiple opioid prescriptions
- Patient accessed 21 different GPs across 6 medical practices
- Multiple dispensing pharmacies preventing visibility of total medication burden
- Neurosurgical intervention declined, leaving patient without pain management plan
Coroner's recommendations
- Development and implementation of a real-time prescription monitoring system to prevent prescription shopping and inappropriate polypharmacy
- Enhanced coordination of medical care across multiple prescribers and dispensers
- Systematic solution to information deficit preventing individual clinicians from identifying cumulative medication burden across providers
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