Inquest into the death of MO
Deceased
MO
Demographics
6y, unknown
Date of death
2018-08-06
Finding date
2024-03-26
Cause of death
methadone toxicity
AI-generated summary
A 6-year-old boy died from methadone toxicity after ingesting his parents' takeaway methadone mixed in juice at home. Both parents were on the NSW Opioid Treatment Program (OTP). The prescribing physician increased methadone doses at rates significantly exceeding clinical guidelines and approved excessive takeaway doses (6 per week per parent; 12 total weekly doses to the home). The mother had severe intellectual disability which was not adequately considered. The child had previously ingested his parents' medications in 2013. Dispensing pharmacy staff were unaware of OTP guidelines. Critical lessons: prescribing rates must comply with guidelines; intellectual disability should preclude unsupervised takeaways with children present; pharmacy staff need formal acknowledgment of OTP guidelines; prescribers and dispensers must counsel on methadone storage dangers and emphasize immediate emergency response if a child ingests methadone. Earlier child protection intervention could have identified safety hazards.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- excessive takeaway methadone doses prescribed (6 per parent per week; 12 total weekly to home)
- prescription dose increases at rates significantly exceeding NSW OTP guidelines
- failure to consider mother's severe intellectual disability when prescribing takeaway methadone
- lack of awareness of OTP guidelines by dispensing pharmacy staff
- inadequate safe storage advice to parents
- lack of clear guidance to parents on emergency response if child ingests methadone
- chaotic home environment with hazardous physical conditions
- parents' decision to monitor child at home rather than seek immediate emergency medical attention
- methadone mixed with juice and left unattended
- prior 2013 incident of child ingesting parents' medications not adequately investigated by child protection
Coroner's recommendations
- Reword the declaration on the pharmacy application form for authority to dispense methadone to clarify the ongoing nature of the pharmacist's responsibilities and ensure both employers and any current or future employees who dispense methadone have signed the OTP Guidelines acknowledging in writing their awareness of them
- OTP Guidelines should address the risks of mixing takeaway methadone doses with orange juice or other drinks to mask taste, with firm advice to consumers about dangers of leaving such mixtures unattended or in reach of children
- OTP Guidelines should provide greater guidance to prescribers regarding opioid replacement medication administration to persons with intellectual disabilities, particularly regarding circumstances when takeaways may or may not be appropriate when children are present in the household
- OTP Guidelines should establish guidance to both prescribers and dispensers about advice to give methadone consumers regarding steps to take if they suspect a child has ingested their methadone, emphasizing the utmost importance of seeking urgent medical attention by calling Triple 0
- A flyer from DCJ's 'Alcohol and Other Drugs Kit' regarding safe storage of methadone and buprenorphine and safety procedures if a child ingests methadone should be distributed to every patient on the OTP, with encouragement to display it near their storage cupboard at home
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