Coronial
VIChospital

Finding into death of Sharni Dee Connolly

Deceased

Sharni Dee Connolly

Demographics

37y, female

Date of death

2018-10-22

Finding date

2021-05-01

Cause of death

Multiple drug toxicity

AI-generated summary

Sharni Dee Connolly, a 37-year-old registered nurse turned naturopath, died from multiple drug toxicity following a hamstring injury requiring opioid analgesia. She was prescribed excessive quantities of pregabalin (105mg daily versus 50mg directed) and clonazepam (3.2mg daily versus 1.5mg directed) by her GP, alongside tapentadol, tramadol, temazepam, and diazepam. Her husband observed increasing confusion and dazed appearance. On 20 October 2018, she was found unresponsive with respiratory depression, suffered hypoxic brain injury despite resuscitation, and was declared brain dead. The Coroner's Prevention Unit found pregabalin and clonazepam were prescribed in excess of therapeutic need, with concurrent CNS depressants increasing overdose risk. No systemic prevention opportunities were identified, though the SafeScript real-time prescription monitoring system, introduced after her death and excluding pregabalin, might have prevented this outcome.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

general practiceemergency medicinepain medicineintensive care

Error types

medicationcommunicationsystem

Drugs involved

tapentadoltramadolpregabalinclonazepamdiazepamtemazepamsodium valproatetrimethoprim

Clinical conditions

opioid analgesic dependencechronic pain from hamstring injurypost-natal depressionanxietydepressionmultiple sclerosisrespiratory depressionhypoxic brain injurycerebral oedemamultisystem failure

Contributing factors

  • Excessive prescribing of pregabalin (105mg daily versus 50mg directed)
  • Excessive prescribing of clonazepam (3.2mg daily versus 1.5mg directed)
  • Concurrent prescription of multiple CNS depressants including tapentadol, tramadol, temazepam, and diazepam
  • Cumulative effect of CNS depressant drugs causing respiratory depression and sedation
  • Patient may have obtained early prescriptions and double-dispensing of medications
  • Lack of real-time prescription monitoring between treating doctors
  • Possible depression and suicidal ideation not adequately managed

Coroner's recommendations

  1. The Victorian Department of Health and Human Services should consider the inclusion of pregabalin in the scope of drugs monitored in the SafeScript real-time prescription monitoring scheme to reduce the risk of harm associated with pregabalin
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