Finding into death of Mrs DA

59y · Female·Multiple drug toxicity (propoxyphene, citalopram, oxazepam and others)

Mrs DA, aged 59, died from multiple drug toxicity (propoxyphene, citalopram, oxazepam and others) in March 2014. She had suffered a severe stroke in 2006 with resultant significant disability, chronic pain, and subsequent depression with suicidal ideation. Despite psychiatric involvement and GP care, she remained resistant to supportive interventions and had clearly expressed her intention to end her life over several years. She self-administered a fatal overdose of prescribed medications. The coroner noted this reflected broader end-of-life care issues rather than a failure in clinical management. Key clinical lessons include the importance of recognising persistent suicidal ideation in patients with irreversible disability, offering palliative care and psychosocial support early, and considering escalation despite patient resistance when suicide risk is high.