Coronial
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Doheny, Dominic Raphael

Deceased

Dominic Raphael Doheny

Demographics

36y, male

Coroner

Lock

Date of death

2007-08-29

Finding date

2008-09-12

Cause of death

morphine toxicity

AI-generated summary

A 36-year-old man with morbid obesity, possible sleep apnoea, and respiratory symptoms died from morphine toxicity after taking three 100mg MS Contin tablets within 6 hours, despite being opioid-naïve. He presented to ED with pleuritic chest pain, received 15mg IV morphine, and was discharged with a prescription for 100mg MS Contin tablets twice daily by his GP. He was pain-free after the first dose but continued taking additional tablets with alcohol, contrary to warnings. The coroner found the prescribing decision clinically supportable but concerning given available alternatives. Key lessons: MS Contin 100mg is high-risk in opioid-naïve patients with respiratory compromise; slow-release morphine is inappropriate for acute pain; clear dosing instructions (every 12 hours, not twice daily) and explicit warnings about overdose fatality are essential; patient non-compliance and altered mental state (drowsiness, confusion) at midnight increased risk. The coroner did not refer the prescribing doctor to the Medical Board but recommended stronger labelling requirements and further clinical education in narcotic prescribing.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicinegeneral practicepharmacypathologyforensic medicine

Error types

medicationprescribingcommunication

Drugs involved

morphinemorphinealcoholibuprofenamoxicillin/clavulanatefurosemide

Clinical conditions

morphine toxicityrespiratory depressionmorbid obesitysleep apnoeabronchitispleuritic chest painmusculoskeletal pain

Contributing factors

  • prescription of 100mg MS Contin to opioid-naïve patient
  • morbid obesity (180kg)
  • probable sleep apnoea
  • respiratory symptoms (cough, bronchitis)
  • patient non-compliance with dosing instructions
  • consumption of alcohol with morphine
  • altered mental state (drowsiness, confusion) at time of third dose
  • slow-release formulation inappropriate for acute pain
  • inadequate warning about consequences of overdose
  • discrepancy between prescriber's stated intent (60mg) and actual script (100mg)

Coroner's recommendations

  1. The Therapeutic Goods Administration should consider requiring prescribers or manufacturers of MS Contin or other strong narcotic medication to state dosage specifically in number of hours between doses (e.g. every 12 hours rather than twice daily) and to place clear warnings on insert material and packet that failure to take medication strictly in accordance with instructions may have serious consequences including death.
  2. Dr M. undertake further clinical education in relation to the prescribing of narcotic medication.
  3. The Health Quality and Complaints Commission note the findings and evidence in this case for the purpose of monitoring any trends in the use of prescribed narcotic medication.
Full text
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Source and disclaimer

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