Deceased
Susan Ingrid Robb
Demographics
37y, female
Date of death
2011-08-20
Finding date
2014-05-28
Cause of death
Mixed drug toxicity (methadone, diazepam, clonazepam, amisulpride, olanzapine, haloperidol, chlorpromazine and valproic acid)
AI-generated summary
Susan Robb, 37, was admitted involuntarily to Northern Hospital Psychiatric Unit with deteriorating mental health and on a Community Treatment Order. Three weeks after self-discontinuing methadone, the treating team re-commenced it at the patient's request despite severe psychiatric illness precluding valid consent. Methadone dose rapidly escalated: 20mg to 50mg over 3 days, concurrent with diazepam, clonazepam, and antipsychotics. Death was attributed to mixed drug toxicity. The coroner found critical departures from clinical guidelines: inadequate objective assessment of opioid withdrawal (patient heavily sedated, masking withdrawal signs), inappropriate rapid dose titration, insufficient sedation monitoring despite multiple CNS depressants, and lack of informed discussion. Expert review found re-commencement 'unlikely clinically appropriate'. The service conceded dosages were 'too great and not clinically appropriate'. Key lessons: require objective evidence before re-commencing opioid therapy; implement rigorous sedation monitoring; recognize limitations of standard withdrawal protocols in acute psychiatric settings; document informed consent discussions.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
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