Finding into death of Ms Jane

13y · Female·hypoxic ischaemic encephalopathy secondary to gamma hydroxybutyrate toxicity

Jane, aged 13, died from hypoxic ischaemic encephalopathy secondary to gamma hydroxybutyrate (GHB) toxicity following accidental overdose. She ingested an estimated 6-9mls of GHB in early June 2017, having used the drug only once previously. Jane was relatively naive to GHB's effects. She was resuscitated after cardiac arrest but suffered irreversible brain injury and died two days later. The coroner found no clinical failures by emergency responders or hospital staff, and no inadequate child protection response or support services provision. Jane had engaged well with counselling, education support, and alcohol/drug services in the preceding two years and was making progress. Her death resulted from the unpredictability of the drug and the situation she found herself in, rather than lack of appropriate supports or service failures.