Matthew Douglas McLachlan - Non-inquest findings

Contributing factors

• Opioid dependency developing over time from chronic pain management
• Patient deliberately withheld information from GP about concurrent hospital admission
• GP prescribed additional opioids without knowledge of hospital medications
• Patient accessed medications from multiple sources without disclosure
• Syringes and additional tablets found in bedside drawer suggesting intravenous self-administration
• No effective coordination between hospital and community GP
• Patient history of intravenous drug use not adequately managed
• Patient left hospital unsupervised daily despite known drug history and current medication regimen

Coroner's recommendations

1. Implement systems to enhance communication between hospital and community practitioners regarding concurrent treatment of opioid-dependent patients
2. GPs should routinely verify whether patients presenting with pain are currently receiving inpatient treatment at other facilities before prescribing opioids
3. Hospital policies should include enhanced monitoring and restrictions on unsupervised leave for patients with known substance use history and opioid dependency
4. Consider mandatory disclosure protocols for patients receiving opioid medications across multiple care settings
5. Enhanced staff training on recognizing opioid-seeking behavior and managing substance-dependent patients safely