A coroner has again flagged the importance of discharge summaries being “promptly communicated” to GPs following the death of a patient from prescription drug toxicity.

Kim Bartolo, 47, was originally admitted to Brunswick Private Hospital in October 2021 after sustaining a fractured hip following a fall at home.

With a complex mental health history, she was reviewed by a psychiatrist who decided to change her medications, with the intention of gradually replacing her venlafaxine prescription with duloxetine and her diazepam prescription with oxazepam.

According to Victorian coroner David Ryan, the psychiatrist had explained the cross-titration process to her, and on discharge, she was given a comprehensive medication list and a copy for her GP.