Inquest into the death of W

Contributing factors

• Excessive buprenorphine dosing (20mg over 12 hours versus recommended 8-12mg for first 24 hours)
• Co-administration of buprenorphine with benzodiazepines and other sedating drugs (quetiapine, mirtazapine)
• Failure to escalate care when pinpoint pupils indicating opioid intoxication were documented
• Inadequate nursing response to progressive somnolence on final day
• Lack of increased monitoring despite documented signs of toxicity
• Insufficient physician-nurse communication regarding clinical deterioration
• Absence of daily face-to-face medical review over weekend
• Complex withdrawal management in patient with multiple dependencies and modest opioid tolerance
• Discrepancies between facility medication guidelines and contemporary NSW clinical guidelines

Coroner's recommendations

1. Admit patients with complex needs to Corella Lodge earlier in the week rather than later, to allow maximum medical coverage
2. Conduct a review by addiction medication specialists of the DHS Medication Guidelines for Inpatient Detoxification in light of NSW Clinical Guidelines: Treatment of Opioid Dependence (2018), including appropriate dosing guidelines, guidance on buprenorphine with other sedating drugs, and clarification of PRN and breakthrough doses
3. Provide further training for nurses at Corella Lodge on: DHS Medication Guidelines, NSW 2018 Clinical Guidelines, clinical management and monitoring of sedation with benzodiazepine-buprenorphine co-administration, clinical judgment in PRN/breakthrough dosing, and steps when patients are unexpectedly intoxicated
4. Ensure a copy of the DHS Medication Guidelines for Inpatient Detoxification is available at the Nurses' Station
5. Introduce a sedation chart to observations for patients receiving buprenorphine and/or benzodiazepines