Coronial
VICmental health

Finding into death of Tania Louise De Jong

Deceased

Tania Louise De Jong

Demographics

48y, female

Coroner

Coroner Catherine Fitzgerald

Date of death

2023-04-23

Finding date

2025-12-11

Cause of death

Mixed drug toxicity (morphine, codeine, venlafaxine, amitriptyline and zopiclone)

AI-generated summary

A 48-year-old woman with depression, anxiety, and bipolar disorder died from mixed drug toxicity while on voluntary inpatient psychiatric admission. She had undisclosed significant illicit drug use, which was not identified during initial assessment. During day leave on 23 April 2023, she obtained drugs and subsequently died from overdose involving morphine, codeine, venlafaxine, amitriptyline, and zopiclone. Critical clinical lessons include: the need for rigorous substance abuse screening in mental health admissions, recognition that self-reported drug histories are often inaccurate, importance of comprehensive bag searches after leave, and clear protocols for 'responsible adult' supervision during accompanied leave. The hospital lacked expertise in substance abuse management and should have sought specialist drug and alcohol advice after discovering her cocaine use on 9 April.

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

Specialties

psychiatrygeneral practiceforensic medicine

Error types

systemcommunicationdiagnostic

Drugs involved

morphinecodeinevenlafaxineamitriptylinezopiclonecocaineheroinquetiapinelithiumclonidinesodium valproatetopiramateolanzapine

Clinical conditions

depressionanxietybipolar disordersubstance abuse disorderopioid usecocaine usedrug toxicitycentral nervous system depressionrespiratory depression

Contributing factors

  • Undisclosed significant substance abuse history not identified on admission
  • Inaccurate patient self-reporting of drug use extent
  • Lack of institutional expertise and training in substance abuse recognition and management
  • Inadequate bag search procedures on return from day leave
  • Incomplete visual observation protocols
  • No specialist drug and alcohol advice sought after cocaine use disclosed
  • Unclear protocols for 'responsible adult' supervision during leave
  • Patient able to access drugs while on day leave despite being inpatient

Coroner's recommendations

  1. SEPH should implement a policy whereby any determination to discharge or continue treatment of a patient discovered to be abusing drugs/alcohol should include a requirement to seek advice from an appropriately qualified Alcohol and Other Drugs (AOD) Clinician
  2. Include drug and alcohol experience in future staff recruitment processes
  3. Provide specific drug and alcohol training to all mental health staff and hospital contractors
  4. Require twice weekly reviews of comprehensive care plans and progress notes by Nurse Unit Manager and Allied Health team
  5. Amend Clinical Escalation policy to add escalation of critical information to hospital's on-call executive team
  6. Update Escalation of Mental Health Deterioration policy
  7. Introduce written guidelines for 'responsible adult' regarding accompanied leave
  8. Develop new Patient Leave form with checklist for post-leave bag searches, documentation of return time, and post-leave debriefing
  9. Update Visual Observations policy to standardise observations process including environmental scans
  10. Conduct Code Blue simulations with after-action critiques and debriefing
  11. Review mental health admission packs
  12. Conduct risk assessment training with after-action critiques
Full text
Official source Archived copy

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