Finding into death of Noela McGowan

66y · Female·Complications following paracetamol overdose

A 66-year-old woman died from complications of paracetamol overdose after ingesting Mersyndol (codeine/paracetamol combination tablets). She had developed dependence on over-the-counter Mersyndol over approximately 8 years, using it for pain and sleep. Evidence indicated 'pharmacy shopping'—purchasing from multiple pharmacies to obtain larger quantities. Between June-September 2013, she obtained 760 tablets from one pharmacy alone. The coroner found no fault with emergency or hospital management, which appropriately treated fulminant liver failure. Key clinical lessons: pharmacists must verify therapeutic need before supplying Schedule 3 medicines, limit single packages unless exceptional circumstances exist, and be alert to pharmacy shopping. Real-time monitoring of OTC codeine sales and enhanced warning labels about paracetamol toxicity could prevent similar deaths.