Coroner's Finding: ROGERS Justin Malcolm
Deceased
Justin Malcolm Rogers
Demographics
27y, male
Date of death
2000-06-29
Finding date
2003-03-28
Cause of death
propoxyphene toxicity
AI-generated summary
A 27-year-old man with schizophrenia died of propoxyphene toxicity while in police custody. He ingested a fatal dose of Doloxene capsules prescribed by Dr R. on 27 June 2000. The doctor prescribed 100 capsules to a patient he had never seen before, knowing the patient was accompanied by Andre Connell, who he had already placed on restricted daily dispensing (8 capsules/day) due to known drug abuse. The coroner found the prescription was reckless: Dr R. claimed he wrote a daily-dispensing restriction on the prescription form but this was inconsistent with his police interview and implausible given the critical safeguard could be easily removed. The deceased consumed the entire 100-capsule supply within 39 hours, achieving fatal blood levels. The coroner found Dr R. should have either questioned the legitimacy of the request, prescribed a much smaller quantity, or prescribed a safer alternative analgesic.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- prescription of excessive quantity of Doloxene (100 capsules) to first-time patient
- failure to implement daily dispensing restriction on prescription
- inadequate assessment of drug-seeking behaviour
- patient accompanied by known drug abuser receiving restricted supply of same drug
- patient with untreated schizophrenia and documented drug abuse history
- consumption of 80+ capsules over 39 hours
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