Coroner's Finding: O'NEILL Louise Kay

31y · Female·mixed drug toxicity (propoxyphene, fluvoxamine, and alprazolam)

A 31-year-old woman with extensive history of deliberate self-harm and prescription drug abuse died from mixed drug toxicity (propoxyphene, fluvoxamine, and alprazolam). She presented to the emergency department with a reopened wrist laceration and reported mild analgesia use, but had actually consumed a large overdose of propoxyphene. She was triaged as Priority 4 and deteriorated unexpectedly over 70 minutes while waiting for medical review. Key clinical lessons: patients with self-harm history require higher suspicion for undisclosed overdose; patients requiring barouches in ED must receive documented, frequent vital sign monitoring (every 30 minutes); and system-level ED overcrowding compromises patient safety. The expert opined that undocumented, informal observation of patients on trolleys is inadequate and poses undetected deterioration risk.