Coroner's Finding: KROMWYK Shane Andrew
Deceased
Shane Andrew Kromwyk
Demographics
38y, male
Date of death
2009-03-14
Finding date
2013-09-03
Cause of death
mixed drug toxicity and arrhythmogenic right ventricular dysplasia
AI-generated summary
Shane Andrew Kromwyk, aged 38, died at home on 14 March 2009 while on home detention bail. Post-mortem examination revealed mixed drug toxicity (methadone, diazepam, alprazolam) combined with pre-existing arrhythmogenic right ventricular dysplasia. He had consumed excessive methadone—all two weekend 'takeaway' doses plus his supervised daily dose—achieving potentially lethal blood concentrations. Critical clinical lessons: (1) Kromwyk manipulated multiple doctors ('doctor shopping') without practitioners knowing about concurrent prescriptions from other doctors; (2) Dr W. accepted unsubstantiated claims of heroin addiction to justify methadone prescription shortly after Kromwyk tested positive for non-prescribed methadone; (3) No coordinated medication management or checking of prescription histories occurred; (4) Weekend takeaway methadone dosing in an individual with demonstrated prescription drug abuse and recent bail breach was high-risk. Better practice would involve shared care coordination, verification of addiction claims, awareness of doctor shopping patterns, and more cautious dosing of potentially lethal drug combinations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- excessive methadone consumption exceeding prescribed dose
- unsupervised weekend takeaway methadone dosing
- combination of methadone with benzodiazepines causing additive CNS and respiratory depression
- doctor shopping across multiple practitioners without coordination
- lack of awareness by prescribers of concurrent prescriptions from other doctors
- acceptance of unsubstantiated claims of heroin addiction by Dr W.
- absence of shared medication records between prescribers
- history of prescription drug abuse and recent bail breach not adequately considered in prescribing decisions
- pre-existing cardiac arrhythmogenic right ventricular dysplasia
Coroner's recommendations
- Department for Correctional Services caseworkers should view with appropriate scepticism the actions of clients with a history of drug and medication abuse who seek permission to habitually attend doctor's appointments and pharmacies
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —