Inquest into the death of Gregory MASTERS
Deceased
Gregory Masters
Demographics
52y, male
Date of death
2017-03-02
Finding date
2020-09-25
Cause of death
Polypharmacy overdose of amitriptyline and doxylamine in the context of underlying co-morbidities of obesity, cardiovascular disease and obstructive sleep apnoea
AI-generated summary
A 52-year-old man with chronic facial pain, depression, obesity, cardiovascular disease and obstructive sleep apnoea died following restraint in ICU. He had ingested a polypharmacy overdose of amitriptyline and doxylamine on 26-27 February 2017, was admitted to Nepean Hospital, and successfully managed in ICU. On 2 March, while confused and hypoxic after extubation, he became acutely agitated and refused treatment. After failed de-escalation attempts, he was restrained in prone position to enable sedation with ketamine and midazolam. He deteriorated acutely, requiring intubation and ultimately died. Medical care was appropriate throughout. The coroner found restraint was clinically justified and appropriately conducted, though one security officer's knee briefly contacted his back. The death was primarily caused by polypharmacy overdose exacerbated by comorbidities, with restraint unlikely to have materially contributed. The coroner noted good post-incident training improvements by the health district.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
Contributing factors
- overdose of amitriptyline and doxylamine ingested 26-27 February 2017
- chronic trigeminal neuralgia and facial pain
- depression
- obesity
- obstructive sleep apnoea
- cardiovascular disease
- acute agitation and delirium on 2 March 2017
- hypoxia following extubation
- restraint procedure and associated physiological stress
Full text
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —