The medical community should be warned about the potential toxicity of colchicine, which is used to treat gout, South Australia's coroner says.
An expert told the inquest into the death of Cynthia Joy Werner that he did not believe the relationship between excessive colchicine use and the risk of death was common medical knowledge.
Coroner Mark Johns recommended the state health minister inform practitioners about the potential for toxicity in the use of colchicine and the apparent discrepancies in some publications related to dosage.
In his findings, handed down on Thursday, the coroner did not suggest that colchicine should not be used at all.
He found that Ms Werner, 76, died as a result of colchicine toxicity at an Adelaide nursing home in December 2010.
Colchicine, a substance derived from the plant known as the meadow crocus or autumn saffron, is extracted and used in medications, predominantly for the treatment of gout.
"The evidence of the two experts about colchicine and its potential lethality is a matter that is not well understood within the medical community," he said.
The coroner had no criticism of the doctor who treated Ms Werner, nor of the nursing home.
"In my opinion, this case provides an opportunity to illustrate the dangers of colchicine as an agent for the treatment of gout, and highlights certain ambiguities in some of the published medical guidelines that describe appropriate dosages for colchicine," he said.