Coroner's Finding: Mr A

Contributing factors

• intravenous injection of crushed oral medication
• microcrystalline cellulose binder in pharmaceutical tablets
• pulmonary vascular obstruction
• inflammatory reaction to foreign debris
• history of intravenous drug abuse
• lack of awareness of dangers of injecting oral medications

Coroner's recommendations

1. That relevant agencies consider whether there is a need for a public education campaign with a view to reducing the harm caused by illicit diversion of psychostimulants, and in particular, to highlight the dangerous practice of intravenous injection of such substances
2. That in developing updated guidelines for the issuing of authorities to prescribers, the PSB consider current evidence of the prevalence of and harm caused by diversion and misuse of psychostimulants in the community
3. That medical practitioners prescribing psychostimulant medication such as Ritalin continue to be vigilant in assessing the serious risks associated with such prescription and to ensure that careful assessment, planning, diagnosis, treatment and monitoring occurs in association with such prescribing