SJM - Non-inquest findings
Deceased
SJM
Demographics
57y, male
Date of death
2012-07-08
Finding date
2016-08-22
Cause of death
Mixed drug toxicity, predominantly propoxyphene (Doloxene)
AI-generated summary
A 57-year-old man died from mixed drug toxicity, predominantly propoxyphene (Doloxene), combined with benzodiazepines. His GP of 13 years prescribed Doloxene for 10 years despite documented alcohol abuse history, which was contraindicated. The GP also prescribed multiple central nervous system depressants (Temazepam, Alprazolam) concurrently, significantly increasing overdose risk. The GP prescribed large quantities (100 capsules at a time) without adequate monitoring, despite the patient exceeding recommended daily doses (8 tablets/day vs maximum 6). No alternative pain management strategies, specialist referrals, or genuine medication reduction plans were documented. Key clinical lessons: Doloxene should be avoided in patients with substance abuse history; concurrent CNS depressants require careful justification and monitoring; long-term benzodiazepines need regular review and specialist input; prescribing practices require documentation of clinical reasoning, baseline investigations (ECG, renal function), and regular reassessment.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Long-term prescription of Doloxene despite documented alcohol abuse history and contraindication
- Concurrent prescription of multiple central nervous system depressants (Temazepam, Alprazolam)
- Patient exceeding recommended daily dose of Doloxene (8 tablets/day vs maximum 6)
- Prescribing large quantities of Doloxene without adequate monitoring or dose control
- Lack of genuine medication reduction plan despite documented dependence
- Absence of baseline cardiac and renal investigations despite documented cardiac risk factors
- No exploration of alternative pain management strategies or specialist referrals
- Prescriptions written without documented consultations
- Long-term benzodiazepine use (13 years Temazepam) without appropriate review or tapering
- Underlying cardiac pathology (enlarged dilated heart, degenerative changes)
- Underlying metabolic syndrome and diabetes
Coroner's recommendations
- Referral to Office of the Health Ombudsman for assessment and disciplinary action regarding Dr JB's prescribing practices
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