Coroner's Finding: CE de-identified

69y · Male·amitriptyline and alcohol toxicity with ischaemic heart disease

A 69-year-old man with longstanding anxiety, depression, heavy alcohol use, and multiple prior intentional overdoses of amitriptyline died from combined amitriptyline and alcohol toxicity with underlying ischaemic heart disease. After a serious intentional overdose in May 2020 requiring ICU admission, hospital psychiatry directed cessation of amitriptyline. However, the prescribing GP received this discharge advice late and the patient obtained two repeat prescriptions from different pharmacies within 24 hours (100 tablets total), falsely claiming a lost prescription. The coroner found no fault with the pharmacist or GP individually but identified a critical system failure: hospital discharge summaries containing urgent medication cessation advice were not immediately communicated to GPs and pharmacies, enabling the patient to access a contraindicated medication that he fatally overdosed on.