Coroner's Finding: ROWAN Marjorie June

52y · Female·ischaemic and hypertensive heart disease

A 52-year-old woman with depression, diabetes, and hypertension died at home from ischaemic and hypertensive heart disease. She was prescribed dothiepin 225mg daily for depression management. Following gallbladder surgery in April 2009, she had deranged liver function tests (elevated GGT and ALP). The coroner examined whether dothiepin should have been reduced given the liver dysfunction. Expert evidence from hepatologists and clinical pharmacologists confirmed her liver function impairment was cholestatic (from gallstones) rather than hepatocellular damage, and her overall drug metabolism capacity remained normal. The dose of dothiepin was standard and appropriate. No treating doctor acted inappropriately. Post-mortem toxicological findings were likely explained by post-mortem redistribution from the stomach rather than acute overdose. The death was not preventable based on available clinical information.