Inquest into the death of Heather Fotiades
Deceased
Heather Fotiades
Demographics
43y, female
Date of death
2015-07-20
Finding date
2017-05-05
Cause of death
acute multiple drug toxicity on a background of chronic pain and morbid obesity
AI-generated summary
A 43-year-old woman died from acute multiple drug toxicity after 26 years of high-dose opioid therapy for chronic pain following a motor vehicle accident. Despite recognition by multiple clinicians that opioid doses exceeded safe levels (220-230mg OxyContin daily equivalent to 330-345mg morphine) and were ineffective for pain, doses were not reduced and were actually increased following hip replacement surgery. Key clinical failures included: lack of coordinated management plan between specialists and general practitioners; failure to detect prescription shopping when patient obtained opioids from two prescribers simultaneously; prescribing multiple opioids concurrently with sedating drugs in an obese patient with respiratory risk factors; discharge from hospital on higher opioid doses without tapering plan; and absence of addiction medicine specialist input. The coroner found this was a preventable death that should have been foreseen.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- long-term high-dose opioid therapy for non-cancer chronic pain
- opioid doses known to be ineffective due to tolerance
- failure to implement tapering plan despite medical recognition of risk
- prescription shopping undetected - patient obtaining opioids from two prescribers simultaneously
- lack of written management plan
- lack of coordination between specialists and general practitioners
- prescribing multiple opioids concurrently (methadone and endone)
- concurrent use of sedating medications (amitriptyline, pregabalin, zolpidem)
- take-as-required opioid dosing in patient identified as drug-dependent
- discharge from hospital on increased opioid doses
- obesity with rapid weight gain
- multiple respiratory risk factors (previous airway surgery, asthma, possible sleep apnoea)
- abnormal liver function affecting drug metabolism
- absence of addiction medicine specialist input
- drug management system failures - non-real-time, failed to detect prescription shopping
Coroner's recommendations
- Implement real-time monitoring of Schedule 8 drugs in the Northern Territory as soon as possible
- Give consideration to maximum prescribing levels for opioids
- Implement restrictions on provision of unnecessary opioids to patients being discharged from hospital
- Ensure collaboration between Pain Specialists and Addiction Medicine Specialists for safe use of addictive medications
- Improve Drug Management System to detect prescription shopping and unsafe dosing patterns
- Analyse available prescribing data to detect high-risk and inappropriate prescribing
- Modify contracts for opioid pharmacotherapy to include provision for secondary prescriber in emergencies
Full text
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