Finding into death of Finding Ms RF

50y · Female·Potentially fatal multiple drug toxicity (oxycodone, mirtazapine, citalopram, clonazepam, pregabalin) in a woman with epilepsy

Ms RF, a 50-year-old woman with epilepsy and chronic pain from a workplace wrist injury, died from potentially fatal multiple drug toxicity involving oxycodone, mirtazapine, citalopram, clonazepam, and pregabalin. She engaged in prescription shopping across six medical practices and six pharmacies, consulting 21 different GPs between January and September 2013. In September alone, she was prescribed 180 codeine/paracetamol tablets, 112 pregabalin, and 96 oxycodone tablets—approximately three times recommended monthly doses. Individual clinicians had sound clinical bases for their prescriptions given her documented pain history, but lacked visibility of her shopping across providers. The coroner found no individual prescriber at fault but highlighted the absence of real-time prescription monitoring as a critical system gap enabling preventable polypharmacy deaths.