Gemma Louise Macdonald · Prevention of Future Deaths report

On 4 December 2019 I commenced an investigation into the death of Gemma Louise Macdonald aged 22 who died on 22 July 2019.

The investigation concluded at the end of the inquest on 5 December 2019. The medical cause of death was found to be:

1a. Multiorgan failure
1b. Mixed drug overdose
2 Depression

The conclusion of the inquest was that Gemma died following a massive overdose of medication some of which was purchased online and taken at home on 21 July 2019. It was clear from the evidence that she did not intend the overdose to be fatal but rather it was more likely she had been responding to voices, the balance of her mind being disturbed.

Gemma had been known to the mental health service since 2011 following a drug overdose. She was being prescribed medication to help her to sleep and to manage her anxiety and depression, namely Sertraline, Zopiclone and Amitriptyline, which was restricted to weekly prescriptions.

On 1 July she made a purchase of 20 packs of 16 Aspirin 300mg online from 1st For Health International Limited (1st For Health). On 18 July she made an identical purchase, again from 1st For Health. On 1 July 2019 she also purchased 4 packs of 20 Nurofen 400mg from StockX Limited.

Gemma told the paramedics and later the hospital clinicians that she had ingested:
400 Aspirin 300mg
80 Nurofen 400mg
7 Zopiclone 7.5mg
10 Loperramide 2mg
14 Morphine 10mg
70 Sertraline 100mg
35 Amitriptyline 10mg
56 phenoxymethylpenicillin 250mg

Gemma ingested all 693 tablets within 30 minutes and vomited twice, once with tablets evident. The tablets were taken between 8-9pm on 21 July. She died from an overdose on 22 July 2019.

(1) The availability of large quantities of medication to purchase on online by an individual;
(2) Whether there is a system for establishing the suitability of the purchaser;
(3) Whether there is verification process enabling the limiting of transactions to the amount of medicine and frequency of ordering