Deceased
NJ
Demographics
35y, female
Date of death
2015-05-01
Finding date
2017-07-04
Cause of death
combined drug toxicity
AI-generated summary
A 35-year-old woman with long-standing substance use disorder, depression, and chronic pain died from combined drug toxicity involving methadone, pregabalin, methamphetamine, benzodiazepines, mirtazapine, promethazine and paracetamol. Critical clinical failures included: prescription shopping across multiple clinics (at least 4 doctors prescribing overlapping pregabalin, benzodiazepines, and mirtazapine); contraindicated benzodiazepine prescribing despite documented substance use disorder and opioid replacement therapy; long-term benzodiazepine use without cessation strategy; and unsupervised methadone dosing (5 doses weekly) despite multiple risk factors. Doctors failed to notify Drugs and Poisons Regulation despite awareness of drug dependence. No real-time prescription monitoring existed. Better coordination between prescribers, adherence to prescribing guidelines for benzodiazepines and pregabalin, supervised methadone dosing, and a prescription monitoring system could have prevented this death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
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