Coroner's Finding: Murray, Erin Paige and Patterson, Amy Jean

Female·pentobarbitone toxicity

Two veterinary-associated women (a veterinary student and a practicing veterinarian) died from pentobarbitone toxicity via ingestion, with evidence of intentional self-harm. The coroner identified that both women had access to lethal pentobarbitone through veterinary workplaces despite it being a Schedule 4 substance requiring only public exclusion. Key clinical lessons: pentobarbitone, a highly concentrated and rapidly fatal veterinary euthanasia drug, was stored in unlocked cupboards/drawers in workplace settings where colleagues and students could access it. The coroner found that Schedule 8 classification (requiring locked storage) would have prevented access by non-veterinarians. Mental health support systems were inadequate in the veterinary profession. Recommendations included legislative amendment to regulate all veterinary premises, up-scheduling pentobarbitone to Schedule 8 nationally, and developing holistic mental health and mentoring programs for veterinary staff dealing with documented elevated suicide rates in this profession.