Coroner's Finding: TATCHELL Melissa Jay

28y · Female·bronchopneumonia complicating oxycodone toxicity

Melissa Jay Tatchell, aged 28 with severe anorexia nervosa (BMI 11.8, weight 29kg), died from bronchopneumonia complicating oxycodone toxicity. A locum doctor with no prior experience with oxycodone prescribed inappropriate high-dose oxycontin (80mg once daily on 28 September 2007) to a profoundly underweight, debilitated patient. The patient's documented claims of prior hospital-prescribed dosing were uncorroborated. RAH staff failed to review or challenge the oxycontin dosage despite the patient exhibiting severe overdose symptoms (drowsiness, falling asleep mid-sentence) during admission. Staff advised the patient to break slow-release tablets in half—contradicting pharmaceutical guidance and increasing absorption rate. Oxycontin combined with diazepam created additive respiratory depression. Poor medication governance at the residential facility allowed unclear administration. The death was likely preventable with appropriate prescriber supervision, medication review at hospital discharge, and staff vigilance regarding overmedication signs.