Finding into death of P A
Deceased
PA
Demographics
26y, female
Date of death
2021-09-12
Finding date
2023-05-10
Cause of death
Pentobarbitone toxicity
AI-generated summary
PA, a 26-year-old veterinary nurse, died by suicide on 12 September 2021 using pentobarbitone accessed from her workplace. She had a history of depression and anxiety managed by her GP with antidepressants, but had become non-compliant with medication due to cost and was not engaged in mental health treatment at time of death. The Coroners Prevention Unit found no clinical management failures by her treating GPs. However, the clinic breached TGA regulations by storing pentobarbitone in an unlocked cupboard accessible to all staff including PA. Multiple cumulative stressors contributed: workplace dissatisfaction, recent euthanasia of her beloved dog, witnessing a joey struck by a car, relationship breakdown, and unsuccessful job application. Clinic immediately implemented improved drug storage and staff mental health support. Coroner commended these changes and made recommendations for escalation processes and industry-wide compliance with pentobarbitone storage regulations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Non-compliance with antidepressant medication due to cost
- Cumulative suicide stressors: workplace dissatisfaction/perceived bullying
- Euthanasia of beloved family dog
- Witnessing death of joey by motor vehicle
- Relationship breakdown
- Unsuccessful job application
- Breach of TGA regulations regarding pentobarbitone storage at veterinary clinic
- Unauthorized access to pentobarbitone through workplace
- Lack of engagement with mental health services at time of death
- No escalation or safety planning despite documented suicidal thoughts
Coroner's recommendations
- That Castlemaine Veterinary Clinic ensure that escalation processes are in place regarding deviations from expected practice around the use, storage and monitoring of pentobarbitone
- That Castlemaine Veterinary Clinic ensure that all staff are educated around escalation processes if they identify deviations from expected practice around the use, storage and monitoring of pentobarbitone
- That the Veterinary Practitioners Registration Board of Victoria encourage its members to identify deviations from legislation and guidelines around the safe use, storage and monitoring of pentobarbitone and escalate these appropriately
- That the Veterinary Practitioners Registration Board of Victoria encourage its members who operate veterinary practices communicate to their staff the expectations for use, storage and monitoring of pentobarbitone when deviations from policies and expected practice are identified, with safety and prevention focus
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