Inquest into the death of Robert MAXFIELD
Deceased
Robert Maxfield
Demographics
45y, male
Date of death
2019-06-09
Finding date
2021-03-09
Cause of death
multiple drug toxicity
AI-generated summary
Robert Maxfield, a 45-year-old inmate at Cooma Correctional Centre, died from multiple drug toxicity involving methadone and mirtazapine. He had a history of drug dependence and mental health conditions (schizophrenia, depression) managed with olanzapine and mirtazapine. Although not enrolled in the methadone program, he obtained methadone covertly—likely through diversion from other inmates or unauthorised sources. His mirtazapine levels exceeded prescribed amounts, suggesting overuse. The coroner found no deficiency by correctional or health services. Clinical lessons include: recognising overdose risk in inmates with substance use histories; monitoring medication compliance in custody settings; and considering alternative opioid treatments (buprenorphine injections) to reduce diversion opportunities.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Contributing factors
- unauthorised ingestion of methadone obtained covertly within correctional centre
- elevated mirtazapine levels exceeding prescribed dose
- history of opioid and illicit drug dependence
- medication diversion from authorised methadone program participants
- self-administration of monthly medication packs without direct supervision
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