Deceased
Kim Marie Bartolo
Demographics
47y, female
Coroner
Coroner David Ryan
Date of death
2021-12-26
Finding date
2025-01-20
Cause of death
Mixed drug toxicity (venlafaxine, duloxetine, mirtazapine, oxycodone, tapentadol, benzodiazepines)
AI-generated summary
Kim Bartolo, a 47-year-old woman with depression, anxiety, alcohol use disorder and chronic conditions, died from mixed drug toxicity involving multiple prescription medications. She was admitted to Brunswick Private Hospital in October 2021 with a fractured hip and psychiatric review introduced a cross-titration medication regime (replacing venlafaxine with duloxetine, diazepam with oxazepam). Critical clinical lessons: The discharge summary failed to document this cross-titration plan and was not communicated to her GP. At subsequent telehealth appointments, the GP, unaware of the planned medication changes and lacking the discharge summary, prescribed overlapping medications including both old and new antidepressants plus opioids. This resulted in dangerous polypharmacy with venlafaxine and duloxetine at toxic levels. Better communication of discharge summaries documenting medication transitions, especially involving psychiatric treatment, is essential to prevent duplicate prescribing and drug interactions.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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25y · Male·Combined drug toxicity
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