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The Otago Southland coroner has recommended his finding into the death of an Invercargill woman be read by Southern District Health Board (SDHB) staff, saying the woman was not advised about the effect of strong painkillers prescribed to her after surgery.
Sharon Alice Mary Riseley (58) was found dead in her bed at her Invercargill flat on June 16 last year.
Coroner David Crerar found she died of an accidental drug overdose.
Nine different drugs were found in her system, including the pain relievers tramadol, ondansetron, paracetamol, amitriptyline and codeine.
Ms Riseley, a sickness beneficiary, had numerous health problems including obesity, diabetes, a hernia, asthma and depression.
Three days before her death she had neck surgery at Southland Hospital to replace a spinal disc. The surgery was described as ''uncomplicated'' and she was sent home with a prescription for tramadol - with instruction to take up to eight tablets a day - and ondansetron.
Police inquiries indicated Ms Riseley had taken 13 tramadol tablets between collecting the prescription and her death, one more than the recommended dose.
The amount of tramadol in her system was higher than expected for normal therapeutic use, but below levels normally associated with overdose fatalities from tramadol by itself, an Environmental Science and Research (ERS) report said.
However, the presence of tramadol with other medications she was already taking was likely to have a greater ''depressant action'' than if individual drugs had been taken by themselves, the report said.
Mr Crerar said there was no evidence Ms Riseley knew or understood that taking several medications at the same time was a danger to her.
''There is no evidence as to the counselling offered by the hospital or by the general practitioner in relation to recommended dosages, or warning of combined addictive effects.
''It must be accepted that Sharon Riseley was debilitated by her illnesses. Other persons not so debilitated may have satisfactorily survived similar dosages.''
Mr Crerar did not censure hospital personnel but recommended his findings be read and considered by SDHB staff.