Coroner's Finding: de-identified TX

Contributing factors

• Depression and suicidal ideation
• Anxiety disorder
• Opioid use disorder
• Inadequate risk assessment by general practitioners
• Failure to access DORA prescription monitoring system
• Lack of documented treatment plan
• Absence of risk mitigation strategies
• Escalating benzodiazepine doses without clear monitoring
• Insufficient mental health assessment

Coroner's recommendations

1. General practitioners prescribing benzodiazepines to patients with substance use disorder history should seek and obtain information concerning the patient's substance use history via DORA
2. Doctors should document clear goals of treatment with timeframes and expected undertakings, with such documentation available to all clinicians in the practice
3. Risk mitigation strategies should be implemented such as frequent urine drug screens, comprehensive patient reviews, and frequent full-bodied checks for signs of injecting
4. A plan should be implemented to prescribe the lowest effective dose of a benzodiazepine for the shortest possible time in line with correct therapeutic guidelines
5. Collateral information concerning a patient's mental health and substance use history should be actively sought
6. Comprehensive mental health assessment and monitoring should be documented, particularly when patients have disclosed suicidal ideation to family members