AN INQUEST INTO THE DEATH OF LESLEY MAREE SMITH

47y · Female·Sudden Unexpected Death in Alcohol Misuse (SUDAM)

Lesley Maree Smith, 47, died at home on 9 May 2013 from Sudden Unexpected Death in Alcohol Misuse (SUDAM). She had chronic alcohol misuse (2 bottles nightly) and was prescribed diazepam by her GP, Dr H., starting April 2013 for alcohol withdrawal symptoms without specialist addiction training or formal guidelines. Autopsy revealed alcoholic liver disease with fatty infiltration. While expert evidence excluded direct medication toxicity or cardiac disease as causes, the coroner identified clinical concerns: Dr H. prescribed sedatives to an alcohol-dependent patient without specialist referral, without explicit warnings about sedation or drug interactions, and without baseline liver function testing or documented withdrawal protocols. The coroner did not attribute death to medication but recommended RACGP review treatment guidelines for substance use disorders in general practice and baseline blood testing before commencing treatment.