Deceased
Mark Anthony O'Brien
Demographics
58y, male
Coroner
R.M COOK
Date of death
2016-05-22
Finding date
2019-06-20
Cause of death
Heroin toxicity
AI-generated summary
58-year-old man with chronic back pain, paranoid schizophrenia, and decades-long prescription opioid and benzodiazepine abuse died from heroin toxicity. He had been successfully withdrawn from opioids (MS Contin, Endone) during a March 2016 hospital admission and referred to rehabilitation. He self-discharged from the Adult Step Up Step Down program on 17 May 2016 against medical advice after staff withheld benzodiazepines due to over-sedation. Five days later, he injected heroin with a companion who observed signs of overdose but believed he had recovered. He was found deceased the following morning. Clinical lessons include: coordinating care between multiple prescribers (GPs, pain management, mental health) to prevent polypharmacy and drug-seeking behaviours; recognising that patients with established addiction patterns may transition to illicit drugs when prescription access is restricted; and ensuring robust follow-up after early self-discharge from rehabilitation programs, particularly for patients with known substance abuse.
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
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