Finding into death of JBV JBV
Deceased
JBV
Demographics
47y, female
Date of death
2022-12-12
Finding date
2026-03-16
Cause of death
Acute alcohol and drug (diazepam, paroxetine) toxicity
AI-generated summary
JBV, age 47, died from acute alcohol and drug toxicity after consuming alcohol combined with prescribed benzodiazepine (diazepam) and SSRI (paroxetine) medications. She had completed rehabilitation treatment for alcohol use disorder on 18 November 2022 but relapsed within days and re-admitted on 27 November. Although progressing well clinically, she absconded from The Hader Clinic on 10 December with another patient and consumed alcohol at venues before being found unresponsive at a hotel. Clinical issues include: high relapse risk immediately after completing addiction treatment; need for robust supervision to prevent absconding from rehabilitation facilities; protocols for notifying family when patients leave treatment unexpectedly; and the synergistic CNS depression risk from alcohol combined with benzodiazepines and SSRIs. The coroner found that earlier family notification would not have prevented the death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Alcohol use disorder with rapid relapse after rehabilitation discharge
- Absconding from treatment facility while under care
- Synergistic CNS depression from alcohol combined with benzodiazepine and SSRI
- Inadequate supervision within rehabilitation facility to prevent absconding
- Failure to notify family of absconding in breach of facility confidentiality protocol
- Pre-existing depression and anxiety
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