Finding into death of Sheridan Louise Burnell
Deceased
Sheridan Louise Burnell
Demographics
24y, female
Date of death
2021-01-02
Finding date
2026-06-24
Cause of death
Mixed drug toxicity
AI-generated summary
Sheridan Burnell, 24, died from mixed drug toxicity following an intentional overdose of prescription medications (lamotrigine and quetiapine) on 2 January 2021. Her mental health care was reasonable and appropriate. The coroner identified concerns with ambulance triage procedures: the 000 call was prioritized as non-urgent (Priority 3) and referred to Secondary Triage, delaying dispatch by 37 minutes. Although compliant with policy, this highlighted risks when patients are alone and unresponsive to triage attempts. Expert evidence suggested earlier hospital transfer would improve survival prospects, though massive overdose might be unsurvivable regardless. The deceased had borderline personality disorder, depression, and ADHD, with ongoing psychosocial stressors. Her friends managed her medications responsibly until she unexpectedly accessed the hidden supply during a crisis. No clinical errors in psychiatric care were identified, and Ambulance Victoria subsequently updated escalation policies for vulnerable patients unable to be contacted.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- intentional overdose of prescribed medications
- borderline personality disorder with suicidal ideation and depression
- history of previous prescription drug overdoses and self-harm behaviours
- recent psychosocial stressors including family separation and home sale
- delayed ambulance dispatch due to Secondary Triage referral
- patient was alone when overdose occurred
- unexpected access to medication supply usually monitored by friends
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