Finding into death of Jodie Overstead
Deceased
Jodie Marie Overstead
Demographics
34y, female
Date of death
2017-07-17
Finding date
2023-05-04
Cause of death
Multi drug toxicity
AI-generated summary
Jodie Overstead, a 34-year-old with epilepsy, anxiety, and chronic pain, died from multi-drug toxicity involving tramadol, codeine, amitriptyline, benzodiazepines and other drugs. She engaged in 'doctor shopping', obtaining prescriptions from multiple clinicians across different practices. In the three months before death, she obtained 460 tramadol tablets (789mg/day vs 400mg maximum), 538 oxazepam tablets (180mg/day), and 575 amitriptyline tablets (174mg/day). Multiple prescribers were aware of drug-seeking behaviour but continued dispensing. Critically, tramadol and amitriptyline are contraindicated in epilepsy as they lower seizure threshold. Prescribers lacked coordination and were unaware of overlapping prescriptions or her seizure disorder. Better prescriber communication, awareness of drug interactions in epilepsy, and real-time prescription monitoring could have prevented this death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Epilepsy
- Prescription drug abuse and dependence
- Doctor shopping across multiple practices
- Lack of prescriber coordination and communication
- Prescriber unawareness of overlapping prescriptions
- Prescriber unawareness of patient's seizure disorder when prescribing seizure-lowering drugs
- Excessive doses of tramadol (789mg/day vs 400mg maximum)
- Excessive doses of oxazepam (180mg/day)
- Excessive doses of amitriptyline (174mg/day)
- Contraindicated drug combinations
- Drug-seeking behaviour not consistently managed
- Absence of antiepileptic medications in final toxicology
Coroner's recommendations
- The Royal Australian College of General Practitioners should develop further training and education materials to highlight the harms and hazardous effects of tramadol, as well as the adverse interactions of tramadol with other contraindicated medications.
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