Finding into death of Allison Judith Allan

43y · Female·Hypoxic ischaemic brain injury resulting from alcohol and sodium valproate toxicity

43-year-old woman with epilepsy and depression died from hypoxic ischaemic brain injury after ingesting 15g sodium valproate and 750ml vodka. Critical failures occurred across multiple settings: VPIC provided incomplete advice without recommending serial serum levels; PDH staff inadequately monitored neurological status during a 2-hour gap, failed to escalate deterioration to senior staff, and over-relied on initial VPIC guidance; WBH delayed dialysis initiation by >24 hours despite clear indicators (cerebral oedema, cardiovascular instability, metabolic acidosis). Early intubation at PDH, prompt senior escalation, early toxicology consultation, and timely dialysis at WBH could have prevented death. Systemic issues included VPIC staffing shortages and communication failures between health services.