Finding into death of Michael William Gledhill

Contributing factors

• Excessive methadone take-away doses (76mg daily, double usual dose)
• Inaccurate labelling of methadone bottles describing double dose as single daily dose
• Concurrent use of heroin and diazepam with methadone
• Lack of information-sharing between emergency services and treating clinicians about patient's overdose presentation and heroin possession arrest
• Inadequate assessment of patient stability prior to authorizing large quantities of Schedule 8 drug
• Pre-existing significant coronary artery atherosclerosis with up to 80% stenosis of left anterior descending artery
• Absence of supervision or verification of safe storage arrangements for take-away methadone

Coroner's recommendations

1. That the responsible regulatory authorities, The Department of Human Services (Victoria) and the Department of Health (Victoria), establish a clear mechanism of supervision of the safety arrangements for take away dosage of methadone.
2. That there be a prohibition upon take away methadone dosage unless responsible regulatory authorities, the Department of Human Services (Victoria) and the Department of Health (Victoria), are satisfied that safe storage arrangements are in place in the premises in which the drug is to be stored.
3. That the responsible Minister/s give consideration to legislative amendment if necessary to enable the implementation of appropriate levels of supervision and safety arrangements.
4. That the responsible Minister/s give consideration to legislative amendment if necessary to enable the provision of health information, such as overdose events or drug related arrests, to the General Practitioner supervising a patient's pharmacotherapy program such as the methadone maintenance program.