Coronial
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Inquest into the death of Jay Alan Paterson

Deceased

Jay Alan Paterson

Demographics

43y, male

Coroner

Chief Coroner Walker

Date of death

2017-09-04

Finding date

2019-06-25

Cause of death

hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic upper airway injury

AI-generated summary

Jay Alan Paterson, a 43-year-old man with chronic pain and opioid dependence, died from hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic upper airway injury. He obtained 296 oxycodone tablets in August 2017 by leveraging regulatory differences between ACT and NSW, falsely reporting medications stolen or confiscated. On 30 August, Dr R. prescribed additional opioids after a phone call from Mr Paterson's wife raising concerns, without physical examination or verification of medication possession. Mr Paterson was found unconscious on 31 August with toxic levels of oxycodone and clonazepam. Intubation was technically difficult due to anatomical factors and laryngeal calcification; tracheal perforation occurred but was surgically corrected. The coroner found the intubation complications were unavoidable given anatomical findings, but identified systemic issues with cross-jurisdictional opioid prescribing as a public safety matter. No individual clinician referral to AHPRA was warranted.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

general practicepain medicineintensive carepsychiatryanaesthesiaemergency medicine

Error types

systemprocedural

Drugs involved

oxycodoneoxynormoxycodoneclonazepamdiazepampropranololparacetamol

Clinical conditions

opioid dependencepolypharmacy overdosepost-traumatic stress disorderchronic painpneumoniarespiratory distressdifficult intubationtracheal perforationsubcutaneous emphysemahypoxic ischaemic encephalopathybradyasystolic arrest

Procedures

intubationtracheostomyresuscitation

Contributing factors

  • polypharmacy overdose with oxycodone and clonazepam at toxic levels
  • opioid dependence and tolerance
  • prescription drug seeking behaviour
  • leveraging regulatory differences between ACT and NSW
  • lack of real-time prescription monitoring in NSW
  • difficult intubation due to anatomical factors and laryngeal calcification
  • tracheal perforation during intubation
  • psychological distress related to PTSD and relationship breakdown

Coroner's recommendations

  1. There should be instituted a real-time prescription monitoring system in New South Wales, ideally as part of a national system
  2. NSW Health and ACT Health should develop processes and procedures in relation to dealing with drug dependent persons who seek treatment across the two jurisdictions concurrently, addressing information disparity and differences in regulation regarding opioid medication availability
Full text
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Source and disclaimer

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