Deceased
DM
Demographics
43y, female
Date of death
2022-09-10
Finding date
2024-10-09
Cause of death
Combined drug toxicity (tapentadol, sertraline, gabapentin, periciazine, carbamazepine, diazepam, zopiclone, promethazine)
AI-generated summary
A 43-year-old woman with complex psychiatric history including schizoaffective disorder, borderline personality disorder, and chronic suicidality died from combined drug toxicity involving eight medications (tapentadol, sertraline, gabapentin, periciazine, carbamazepine, diazepam, zopiclone, promethazine). She was admitted to hospital on 4 September 2022 following medication overdose and self-harm, placed on an Assessment Order, then discharged on 6 September after psychiatric assessment deemed acute risk not mitigated by admission. She subsequently obtained duplicate prescriptions from two GPs on 7-8 September after claiming medication loss. The coroner found the hospital psychiatric assessment appropriate but identified a critical system failure: the discharge summary was not forwarded to her GPs, preventing them from knowing about the recent overdose and self-harm when prescribing. Earlier communication of discharge information could have informed safer prescribing decisions.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
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