Finding into death of Margaret Helen McCall

60y · Female·hanging

Margaret McCall, a 60-year-old woman with chronic regional pain syndrome and longstanding anxiety and depression, died by hanging. She received multiple ketamine infusions for pain management, with cessation of fentanyl during her July 2012 hospital admission. Pain recurred within 5 weeks of the final infusion, a known limitation of ketamine's temporary effects. She lived alone with multiple stressors including relationship breakdown and perceived family estrangement. While receiving comprehensive medical and psychiatric care in her final weeks, there was no documented plan to manage anticipated pain recurrence post-infusion, or evidence that clinicians understood this risk. The coroner identified absence of evidence-based guidelines for low-dose ketamine administration, follow-up, and pain re-emergence management as a systemic gap affecting safe practice across multiple similar cases.