Coroner's Finding: Cullen, Jason Mark
Deceased
Jason Mark Cullen
Demographics
37y, male
Date of death
2017-06-22
Finding date
2023-12-06
Cause of death
mixed drug toxicity with fentanyl as the principal agent
AI-generated summary
37-year-old Jason Cullen died from mixed drug toxicity with fentanyl as the principal agent. He had chronic idiopathic intracranial hypertension requiring multiple neurosurgeries and was prescribed opioids and benzodiazepines. He developed addiction to these medications, engaged in 'doctor shopping' across multiple practices, and robbed pharmacies to obtain drugs. Following a suicide attempt in May 2017, he was admitted to QEH but staff failed to identify his previous September 2016 suicide attempt despite it being in electronic records. This missed opportunity prevented recognition of escalating suicide risk and his opioid/benzodiazepine dependence. He was discharged after 7 days with close-to-lethal medication combinations and staged dispensing, but died by suicide one week before sentencing. Clinical lessons: careful electronic record review is essential, particularly regarding prior suicide attempts; opioid and benzodiazepine addiction requires specialist addiction medicine input, not just pain management; patients commonly conceal addiction; prescription protocols must involve comprehensive addiction assessment; and multidisciplinary biopsychosocial pain management is critical to prevent despair.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- chronic idiopathic intracranial hypertension
- chronic pain
- opioid and benzodiazepine addiction and dependence
- doctor shopping across multiple general practices
- prescription medication misuse
- depression
- previous suicide attempts
- imminent criminal sentencing for pharmacy robberies
- social isolation
- failure to identify prior suicide attempt during May 2017 admission
- inadequate addiction assessment and management
- lack of specialist addiction medicine referral
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