Coroner's Finding: Janet Carol Rosse
Deceased
Janet Carol Rosse
Demographics
32y, female
Date of death
2007-08-07
Finding date
2010-03-24
Cause of death
Mexiletine toxicity
AI-generated summary
Janet Rosse was a 32-year-old woman with hyperkalaemic periodic paralysis, a genetic neurological condition causing recurring paralytic episodes and chronic pain, and a concurrent history of major depression and anxiety. In August 2007, she was admitted to St Vincent's Hospital with generalised weakness. The neurology team failed to notify her psychiatrist, Dr C., of her admission despite her known psychiatric history and her visibly depressed and anxious presentation immediately prior to discharge. She discharged herself on 7 August 2007 and subsequently took an intentional mexiletine overdose at home, resulting in mexiletine toxicity and death. The coroner found that psychiatric consultation should have been sought before discharge and made recommendations for systematic psychiatric involvement in all neurological inpatients with concurrent psychiatric care.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Hyperkalaemic periodic paralysis with chronic, untreatable course
- Chronic pain and significant physical disability
- Major depression and anxiety disorder
- Failure to notify psychiatrist of hospital admission
- Failure to consult psychiatrist before discharge despite known psychiatric history
- Patient's depressed and anxious presentation prior to discharge
- Patient's feelings of degradation regarding inability to self-care
Coroner's recommendations
- Approval of St Vincent's comprehensive review of administrative processes undertaken partly as result of this death
- Integration of Barbara Walker Centre pain management patient histories with hospital patient histories through organisation-wide electronic Patient Administrative System, ensuring patient's past and ongoing clinical activity information is readily available throughout the hospital
- Active psychiatric consultation should be sought in all cases where neurological inpatients have a current psychiatric history managed by the Barbara Walker Centre
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —