Coroner's Finding: Cook, Courtney Liza

20y · Female·multi-organ failure due to polypharmacy overdose

A 20-year-old woman with depression and borderline personality disorder died from multi-organ failure following a large polypharmacy overdose (13 grams of paracetamol among 78 tablets). She was admitted to the ED where initial blood testing at 3 hours post-ingestion showed 757 μmol/L paracetamol (below 1000 μmol/L threshold), and NAC was not given. Critical failures followed: planned blood testing on day 2 was missed due to unscheduled surgery, and subsequent attempts to obtain blood samples were hampered by communication failures and lack of task prioritization, delaying critical testing until 48 hours post-ingestion. Expert evidence established that NAC within 8 hours would almost certainly have prevented death, and that blood testing on day 2 morning would have shown liver injury and enabled timely intervention with high likelihood of survival. The coroner found suboptimal medical management at the initial hospital prevented a preventable death.