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.
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Specialties
general practicepsychiatrypharmacyemergency medicine
Error types
diagnosticmedicationcommunication
Drugs involved
propoxyphenealcoholcannabiszuclopenthixolunspecified drugs of abuse
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