Coroner's Finding: Cashion, Brett Matthew
Deceased
Brett Matthew Cashion
Demographics
48y, male
Date of death
2016-09-19
Finding date
2020-05-14
Cause of death
combined drug intoxication from morphine and quetiapine
AI-generated summary
Brett Cashion, a 48-year-old man with chronic pain and mental health issues, died from combined morphine and quetiapine intoxication after injecting prescription morphine. He was receiving daily Subutex in Tasmania from addiction services but was also being prescribed morphine by a Melbourne GP, Dr H., whom he consulted regularly under false pretenses. Dr H. was unaware of Cashion's Tasmanian treatment, his history of opioid misuse and doctor-shopping, or the contraindication of combining morphine with Subutex. The coroner found Dr H. should have sought permission to contact Cashion's Tasmanian GP at the outset to verify the safety of prescribing potent opioids. This case illustrates the critical importance of inter-practitioner communication in complex patients with substance use disorder, particularly when patients present with credible histories but atypical profiles for the treating practice.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- prescription morphine obtained from Dr H. in Melbourne without knowledge of Tasmanian treating doctors
- simultaneous use of Subutex and morphine (contraindicated opioid combination)
- lack of communication between Dr H. and Tasmanian medical practitioners
- patient deception regarding reasons for Melbourne visits and withholding information about parallel prescribing
- intravenous injection of oral morphine tablets
- overdose of quetiapine (central nervous system depressant)
- long-standing pattern of opioid misuse and doctor-shopping
- undetected surplus medication supply due to lack of inter-practitioner coordination
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