Inquest into the death of Linus Phillips

Contributing factors

• Methadone (Physeptone) dosages too large
• Induction rate too rapid (20mg to 50mg in 4 days)
• Inadequate medical supervision during induction
• Lack of pre-treatment ECG
• Concurrent QT-prolonging medications: Domperidone and Ciprofloxacin
• Prescription of Stilnox (Zolpidem) during methadone induction
• Severe obstructive sleep apnoea
• Coronary artery atherosclerotic disease
• Poor communication and coordination between Dr H. and Dr H.
• Patient not admitted for inpatient monitoring
• Inadequate knowledge of methadone by prescribers
• Lack of case conference or formal joint management plan

Coroner's recommendations

1. In respect of the Pharmaceutical Regulatory Unit and the Medical Committee, it is appropriate that the requirements for applications for authority to prescribe Physeptone be examined, particularly with regard to the threshold of 400mg as the oral morphine equivalent daily dose ('oMEDD') to be reached before an application is escalated. Additionally, consideration should be given to examining the appropriate information that should be sought from the prescriber about the patient's level of tolerance for Physeptone when applying for authority to prescribe.
2. The NSW Ministry of Health consider what steps should be taken to educate doctors about the existence and the role of the Pharmaceutical Regulatory Unit, with respect to applying for an authority to prescribe and supply drugs of addiction where required under the Poisons and Therapeutic Goods Act 1966.