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Finding into death of Jessinda Kiroyan

Deceased

Jessinda Kiroyan

Demographics

41y, female

Date of death

2019-05-14

Finding date

2021-03-19

Cause of death

Nitrate/nitrite toxicity

AI-generated summary

Jessinda Kiroyan, a 41-year-old woman with a longstanding history of bipolar affective disorder, died from nitrate/nitrite toxicity in May 2019 after intentionally ingesting sodium nitrite obtained from a food ingredient supplier. She had ceased psychiatric treatment in 2014 despite a diagnosis requiring ongoing management. The coroner's investigation identified a marked increase in sodium nitrite suicides in Victoria since 2017, with 20 confirmed cases between 2000 and 2020. The finding highlights potential prevention opportunities including: clinician education about recognising methaemoglobinaemia and using methylene blue as antidote therapy, restricting online suicide method information, secure workplace storage of sodium nitrite, and improved investigation protocols to identify sources and learning pathways. The case underscores the importance of sustained mental health engagement for patients with chronic psychiatric conditions and the emerging public health challenge of sodium nitrite-facilitated suicide.

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

Contributing factors

  • longstanding bipolar affective disorder
  • cessation of psychiatric treatment in 2014
  • mental health disengagement
  • social isolation and family estrangement
  • access to sodium nitrite via online food ingredient suppliers
  • availability of suicide method information online

Coroner's recommendations

  1. Education for clinicians regarding recognition of methaemoglobinaemia in patients presenting with intentional overdose, dark-appearing blood, cyanosis, hypoxia, and hemodynamic instability, with immediate administration of methylene blue as first-line antidote therapy
  2. Targeting online sources of information about sodium nitrite as a suicide method
  3. Ensuring safe storage of sodium nitrite in workplaces where it is used
  4. Consideration of public awareness campaigns regarding dangers of sodium nitrite, balanced against risk of disseminating method information
  5. Investigation into feasibility of restricting access to sodium nitrite while maintaining legitimate industrial and food production uses
  6. Increased focus on investigation of sodium nitrite suicides to establish sources and learning pathways, to develop evidence base for future prevention recommendations
  7. Prioritisation by coroners of establishing sodium nitrite sources and how decedents learned about the method in their investigations
Full text

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