Deceased
LT
Demographics
34y, female
Coroner
Deputy State Coroner Paresa Spanos
Date of death
2022-03-04
Finding date
2026-01-08
Cause of death
Combined drug toxicity (gabapentin, oxycodone, tramadol, diazepam, citalopram, desmethylvenlafaxine, ondansetron, paracetamol)
AI-generated summary
A 34-year-old woman with complex medical history including chronic pain, sleep disorder, anxiety and PTSD died from combined drug toxicity involving gabapentin, oxycodone, tramadol, diazepam, citalopram, desmethylvenlafaxine, ondansetron and paracetamol. She received extensive prescriptions from multiple providers without adequate coordination. Critical failures included: non-compliance with mandatory SafeScript checking by prescribers and dispensers despite 66 system notifications in the year before death; incomplete disclosure of medications by the patient to clinicians; lack of real-time monitoring of gabapentin (not yet on SafeScript); and unconscious bias by prescribers who did not recognize drug-seeking behavior in a patient who appeared 'innocent'. Clinicians appropriately referred to mental health services but the patient delayed engagement. Had SafeScript been properly checked as legally required, prescribers could have coordinated care and identified concerning patterns of drug acquisition from multiple sources.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
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