Finding into death of Damien Perceval
Deceased
Damien Perceval
Demographics
33y, male
Date of death
2009-04-19
Finding date
2012-09-28
Cause of death
Aspiration pneumonia and hypoxic brain injury in a man consuming alcohol and methadone
AI-generated summary
A 33-year-old man with alcohol dependence died from aspiration pneumonia and hypoxic brain injury after consuming approximately 40ml of methadone (not prescribed to him) combined with alcohol. The methadone was prescribed to and supplied by a visiting houseguest with a history of heroin addiction who had legal access to 'take-away' methadone doses. Three adults present—the houseguest, the deceased's partner, and the houseguest's partner—all became aware that the deceased had consumed methadone combined with alcohol, knew he was not a regular user, saw warning labels about the drug's dangers, and observed him becoming seriously incapacitated. Despite this awareness, they delayed calling an ambulance for approximately 1 hour after he became unresponsive and was found vomiting blood. Immediate ambulance notification may have prevented his death. The case highlights failures in take-away methadone supervision and the risks of dispensing Schedule 8 drugs without pharmacy-based oversight.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Provision of prescribed methadone (40ml) to non-user by drug-addicted houseguest
- Delay in calling ambulance of approximately 1 hour despite observing signs of serious distress
- Failure to intervene immediately upon awareness of methadone consumption combined with alcohol
- Lack of supervision of take-away methadone by authorities
- Availability of Schedule 8 drug in home setting without pharmacy oversight
- Three adults present who failed to seek emergency help despite awareness of risk
Coroner's recommendations
- That the Minister for Health take steps to prohibit the supply of 'take-away' doses of the Schedule 8 drug Methadone by drug addicted persons and require that methadone therapy be delivered and administered at a pharmacy premises under the supervision of a registered pharmacist.
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