Finding into death of Caroline Courtenay Webster

53y · Female·Combined drug toxicity (propranolol and insulin)

A 53-year-old registered nurse with longstanding depression, anxiety and benzodiazepine dependency died from combined drug toxicity (propranolol and insulin) in what was determined to be an intentional overdose. Ms Webster engaged in systematic doctor-shopping from at least eight prescribers across four clinics to obtain benzodiazepines and sedatives (particularly zolpidem), while deceiving her treating doctors about her medication use. Despite comprehensive assessments by multiple psychiatrists and the CAT team who identified her clinical deterioration, dependency and impaired judgment, she did not meet involuntary Mental Health Act criteria. Clinicians communicated appropriately once aware of doctor-shopping, but the lack of real-time prescription monitoring delayed detection. She accessed lethal quantities of propranolol (600 tablets via repeats) and likely obtained actrapid insulin from her ICU workplace. No adverse findings were made against any treating practitioners.