Demographics
54y, female
Date of death
2022-10-15
Finding date
2025-12-02
Cause of death
mixed drug toxicity (methadone and diazepam)
AI-generated summary
A 54-year-old woman with long-standing opioid use disorder died from mixed methadone and diazepam toxicity. She had tripled her methadone dose by injecting additional takeaway doses alongside her prescribed pharmacy dose, contrary to prescribing instructions for oral ingestion. Two near-fatal poisoning events in 2022 preceded her death. The coroner found that while Dr T.'s management was not grossly negligent, he failed to adequately reassess clinical stability or implement stricter risk mitigation after these warning signs. Key missed opportunities included: not reducing takeaway doses (particularly consecutive weekend doses), not documenting detailed risk-benefit assessments, not increasing urine drug screening frequency, inadequate investigation of reports she was diverting methadone, and not pursuing addiction specialist referral more forcefully. The coroner noted that stricter adherence to Tasmanian opioid pharmacotherapy guidelines, particularly limiting takeaway doses and avoiding concurrent benzodiazepines, might have prevented this death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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