Finding into death of Elizabeth Jean Hanlon

38y · Female·Pulmonary thromboembolism secondary to deep venous thrombosis due to promethazine overdose

Elizabeth Jean Hanlon, aged 38, died from pulmonary thromboembolism secondary to deep venous thrombosis following a promethazine overdose. She had complex mental health diagnoses including borderline personality disorder, intellectual disability, and epilepsy, with a long history of self-harm behaviors and psychiatric admissions. On 25 January 2021, she ingested 50 promethazine tablets at her SDA (Specialist Disability Accommodation) home while under 24/7 support worker supervision. She was admitted to ICU at Casey Hospital where she developed aspiration pneumonia, sepsis, and myocardial infarction before dying on 10 February 2021. The coroner found that Monash Health's discharge planning and the subsequent SDA care team (including behavioral support specialist, psychologist, and occupational therapist) provided appropriate, high-standard care balancing Ms Hanlon's dignity of risk against safety needs. Although family raised concerns about independent shopping access to medication, the coroner identified no clear prevention opportunities, as complete risk mitigation would have been impossible despite comprehensive planning.