SMEETON Debra

Contributing factors

• Inadequate communication to carer about lethality of dothiepin
• Prescription regime allowing dangerous stockpiling via authority prescription
• Failure to conduct private consultations with patient
• Failure to identify and respond to patient's psychotic symptoms (hearing voices)
• Failure to escalate to hospitalisation on 10 November despite clinical deterioration and cardiac signs
• Inadequate safety planning despite known high-risk history
• Use of cardiotoxic tricyclic antidepressant when safer SSRIs available
• Rapid dose escalation without adequate clinical review or monitoring
• Patient concealment of psychotic symptoms due to feelings of burden to family

Coroner's recommendations

1. Medical practitioners should be educated about the perils of tricyclic antidepressant overdose and encouraged to consider dothiepin as a last resort due to cardiotoxicity
2. Dothiepin should be available in lesser dosages (e.g. 50mg) or smaller packet quantities to reduce overdose risk
3. Dothiepin should be moved to pharmaceutical schedule category allowing 5 repeats with 20-day minimum dispensing interval to prevent stockpiling
4. Prescribers should limit medication to few days supply during acute phase by arrangement with pharmacist rather than authorising large quantities
5. Formal mechanism should be implemented to ensure written prescription instructions match verbally altered medication instructions
6. Treating doctors should review patient privately for part of each consultation to enable disclosure of symptoms reluctant to share with family
7. Treating doctors should also review patient in presence of family member to canvass medication changes and validate accounts
8. Treating doctors should speak regularly and privately with family members to discover symptoms not volunteered by patient
9. Family members should be informed of warning signs of deterioration, particularly delusional thoughts or hallucinations
10. Written safety plans should be established and provided to family, with particular emphasis on medication control and removal of self-harm items
11. Psychiatric facilities should always prepare discharge summaries and forward to community professionals involved in future care
12. Patients at high risk should be reviewed by community professional soon after discharge to establish continuity of care and baseline for monitoring