Deceased
Andrew John Gilbertson
Demographics
42y, male
Date of death
2019-09-15
Finding date
2022-11-08
Cause of death
methadone toxicity
AI-generated summary
Andrew Gilbertson, a 42-year-old man with bipolar disorder and substance use disorder, died from methadone toxicity while in custody at Long Bay Correctional Centre. He was not enrolled in opioid substitution therapy but had diverted methadone in the past. He failed to attend a scheduled Drug and Alcohol appointment on 10 September 2019, one week before his death. The coroner found the death was due to misadventure—ingestion of diverted methadone without tolerance. Key clinical lessons include the risks of unmanaged opioid diversion in custodial settings and the importance of completing pre-release assessments. Justice Health subsequently implemented monthly buprenorphine depot injections as standard opioid substitution therapy in January 2020, preventing diversion and reducing fatal overdose risk.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
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