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Inquest into the death of Alexandria Catherine Forrester

Deceased

Alexandria Catherine Forrester

Demographics

39y, female

Date of death

2021-09-21

Finding date

2025-10-17

Cause of death

Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to methadone toxicity

AI-generated summary

A 39-year-old woman with opioid dependency died from cardiac arrest caused by methadone toxicity. She had been prescribed up to six take-away doses of 120mg methadone per week by her GP under Queensland's Opioid Treatment Program, contrary to clinical guidelines which recommend maximum four doses per week for low-risk patients and none for high-risk patients. Her risk profile included psychiatric deterioration, presentation with acute confusion and track marks suggesting injection use, benzodiazepine co-prescription, and domestic violence. The deceased injected multiple methadone doses on the morning of her death. The coroner found the GP's prescribing decisions were inappropriate, not based on documented risk assessment, lacked specialist consultation, and contributed to her death. Recommended changes include clearer guidelines on supervised dosing, naloxone provision, agent authorisation, and communication between prescribers and pharmacists.

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

Specialties

addiction medicinegeneral practicepharmacyemergency medicineintensive care

Error types

diagnosticmedicationcommunicationsystemdelay

Drugs involved

methadoneclonazepamdiazepamoxazepam

Clinical conditions

opioid dependencybenzodiazepine dependenceanxietyepilepsy (probable psychogenic), domestic and family violenceanorexia nervosahepatitis Cacute confusionmemory impairmentmethadone toxicitycardiorespiratory arrest

Contributing factors

  • prescription of excessive take-away methadone doses contrary to guidelines
  • lack of risk assessment documentation
  • lack of specialist consultation despite deviations from guidelines
  • poor clinical record-keeping
  • concurrent benzodiazepine prescribing
  • no urine drug screening performed
  • authorisation of medication collection by unnamed agents
  • failure to return to supervised dosing despite clinical deterioration
  • ambiguous prescription instructions
  • injection of prescribed oral medication

Coroner's recommendations

  1. Queensland Health consider amendments to the 2023 Guidelines to clarify that Methadone be diluted to 200mL by removing reference to 'up to 200mL'
  2. Extend provision of advice to authorised agents who collect self-administered medications for patients regarding dangers of misuse, combination with other drugs, and toxic potential
  3. Narrow the description of agents authorised to collect medications from generic terms such as 'carer' to specific named individuals in extreme circumstances
  4. Provide a non-exhaustive list of high-risk behaviours and circumstances that may impact medication adherence when deciding whether to prescribe self-administered doses
  5. Reduce the recommended number of self-administered methadone doses to non-consecutive doses where patients present with high-risk behaviours or circumstances
  6. Offer refresher training as part of prescriber renewal process regarding injectable Buprenorphine, risks of Methadone overdose, polypharmacy and benzodiazepines, and authorisation of self-administered doses
  7. Disseminate the 2023 Guidelines to key stakeholders of the QOTP
  8. Issue an e-alert regarding the specific risks associated with this case
  9. Consult with relevant professional bodies regarding clinical best practice recommendations and guidance documentation for the QOTP
  10. Continue partnership with pharmacy group stakeholders to support training and information provision about the QOTP
  11. Pharmacy professional bodies disseminate information including the 2023 Guidelines to members regarding QOTP obligations
  12. Pharmacy professional bodies consider offering training to members applying for approval to dispense opioid dependence treatment
  13. Pharmacy professional bodies consult with Queensland Health regarding clinical best practice recommendations and guidance for the QOTP
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