Coroner's Finding: KILEY Carol Anne

55y · Female·Multiple drug toxicity due to combination of alcohol and benzodiazepines (oxazepam at toxic level and temazepam at high therapeutic level)

Carol Anne Kiley, a 55-year-old woman with chronic back pain, depression, and likely alcohol dependence, died from multiple drug toxicity involving alcohol, oxazepam (toxic level), temazepam, and promethazine. Her GP, Dr B., prescribed these medications weekly for seven years without in-person clinical review, despite signs of poly-substance dependence and previous alcohol withdrawal seizure. The coroner found Dr B.'s management inadequate: indefinite benzodiazepine prescriptions without periodic assessments, failure to arrange psychiatric referral despite knowing her psychiatric history, and inadequate clinical notes. A critical delay in seeking help—the deceased likely collapsed in the early morning but was not found until 3 pm—may have been preventable had the live-in registered nurse properly recognized the emergency. The case illustrates risks of enabling benzodiazepine-alcohol dependence through loose prescribing practices without engagement of drug and alcohol services or meaningful psychiatric oversight.