Deceased
Paul Fennessy
Demographics
21y, male
Coroner
Coroner Hunter
Date of death
2010-01-06
Finding date
2016-12-16
Cause of death
combined effect of a cocktail of drugs causing central nervous system depression and respiratory depression leading to positional asphyxia
AI-generated summary
Paul Fennessy, a 21-year-old with polysubstance addiction and mental health issues, died from positional asphyxia following a drug overdose on 6 January 2010. He presented to the Emergency Department that afternoon after overdosing on methadone, benzodiazepines and heroin, was resuscitated with Narcan, and discharged the same evening. Critical failures included: no discharge summary despite recent multiple overdoses; incomplete mental health assessment by CAT team without reviewing current ED medical notes documenting he "didn't care if he died"; lack of coordination between Mental Health and Alcohol & Drug Services; no referral to addiction specialist despite multiple overdoses; receipt of a second methadone dose from pharmacy hours before death; and absence of any safety planning for a homeless, highly intoxicated patient. System-level failures included inability to detect prescription drug misuse across multiple providers, lack of real-time monitoring of controlled medicines, and emphasis on patient self-referral rather than proactive care for someone clearly unable to self-manage.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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