Finding into death of PC

20y · Male·pulmonary oedema due to acute on chronic heart failure resulting from dothiepin overdose

A 20-year-old man died from pulmonary oedema due to acute-on-chronic heart failure resulting from dothiepin overdose. He had complex mental health and substance use issues dating back to age 16. He was prescribed dothiepin 300mg daily by a psychiatrist—well above the recommended maximum of 200mg—and this high dose was continued for five months after becoming ineffective. Key clinical failures included: absence of dual diagnosis approach to comorbid mental illness and substance abuse; inadequate psychiatric follow-up after the therapeutic relationship broke down; failure to review or reduce an excessive dose that the psychiatrist himself worried could cause overdose; and dispensing large monthly quantities of a highly toxic drug to a young man at suicide risk. Dothiepin is substantially more lethal in overdose than other antidepressants and should only be prescribed as a last resort with careful monitoring. The coroner found multiple missed opportunities for prevention.