Finding into death of Janet Foster

55y · Female·Mixed drug toxicity in a woman with cardiomegaly and chronic obstructive airway disease

Janet Foster, 55, died from mixed drug toxicity involving heroin/morphine combined with benzodiazepines in the context of cardiomegaly and chronic obstructive airway disease. She was a voluntary palliative care patient at a residential aged care facility with a history of opioid and alcohol dependence. After a dispute with her GP regarding opioid reduction on 6 June 2016, she left the facility and returned to her home. That evening, nursing staff appropriately reported her missing to police and requested a welfare check. However, Sergeant Taylor declined to take a missing persons report, deeming it unnecessary because she was a voluntary patient. Police units were not dispatched. She was found deceased the next morning with evidence of intravenous drug use. Key clinical lessons include: ensuring robust communication regarding medication changes in dependent patients; appropriate risk assessment for vulnerable individuals leaving care facilities; and police-health system coordination for welfare checks in high-risk situations.