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Finding into death of Aisha Natasha Khan

Deceased

Aisha Natasha Khan

Demographics

44y, female

Date of death

2023-09-12

Finding date

2026-03-19

Cause of death

Mixed alcohol and drug toxicity (tapentadol, diazepam, mirtazapine, amitriptyline, gabapentin)

AI-generated summary

Aisha Natasha Khan, 44, died from mixed alcohol and drug toxicity following an intentional polypharmacy overdose with alcohol consumption. She had a history of depression, alcohol use disorder, chronic pain, and two prior suicide attempts. On 12 September 2023, she called ACIS (Acute Crisis Intervention Team) expressing suicidal thoughts after consuming alcohol and nine evening tablets. The paramedic occupational therapist appropriately called Triple Zero. However, a significant delay in emergency response occurred: the Triple Zero call-taking system automatically flagged her as 'armed with a razor' (mentioning household items), triggering mandatory police attendance. This delayed paramedic access by approximately 1 hour 48 minutes while police resources were constrained with other priority incidents. The coroner found the mental health treatment was of high standard, but identified systemic issues in emergency dispatch protocols. Earlier medical intervention would have optimised her chances of survival, though the exact timing of irreversibility remains unclear. Key lessons include improving call-taking discrimination between actual weapons involved versus household items present, and ensuring paramedic safety protocols don't unduly delay response to medical emergencies.

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

Specialties

psychiatryemergency medicineparamedicineforensic medicineaddiction medicine

Error types

systemdelaycommunication

Drugs involved

tapentadoldiazepammirtazapineamitriptylinegabapentinalcoholacamprosateparacetamol

Clinical conditions

alcohol use disorderdepressionadjustment disorderperipheral neuropathygastritisorganising pneumoniaaspiration pneumoniacentral nervous system depressionrespiratory depressionapnoeacardiac arrest

Procedures

cardiopulmonary resuscitation

Contributing factors

  • Organising pneumonia
  • Central nervous system depression from polypharmacy and alcohol
  • Delay in emergency response due to armed response protocol
  • Alcohol intoxication reducing ability to seek help and manage cravings
  • Chronic psychosocial stressors (job loss, financial stress)
  • Prior cardiac arrest from overdose increasing medical complexity

Coroner's recommendations

  1. Support for Legislative Council's Legal and Social Issues Committee Recommendation 13: That the Inspector General of Emergency Management undertake and publish a review of emergency ambulance call answer performance in order to improve the call-taking process and reduce cases of over-triaging
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