Deceased
Sandra Michelle Liddy
Demographics
44y, female
Date of death
2015-12-16
Finding date
2017-11-14
Cause of death
Heroin toxicity
AI-generated summary
Sandra Michelle Liddy, aged 44, died from heroin toxicity while on unescorted day leave from an involuntary mental health admission. She had a 25-year psychiatric history with paranoid schizophrenia and polysubstance use disorder but had made significant clinical progress at AMHRU, with stabilised mental state, therapeutic clozapine levels, and three years of minimal substance use. Following a risk assessment on 15 December 2015, she was appropriately granted 6-hour daily unescorted leave. The Coroners Prevention Unit found her care was clinically sound. On 16 December, during approved leave, she used heroin intravenously and overdosed. Critical learning: her lowered opioid tolerance from three years of abstinence meant she did not adjust her heroin dose, creating high overdose risk. The coroner found the clinical care and leave decisions appropriate; the death was an accidental overdose despite appropriate psychiatric management.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
Procedures
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Source and disclaimer
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