Deceased
Shannon James Lees (Peat)
Demographics
23y, male
Coroner
Coroner Audrey Jamieson
Date of death
2012-02-06
Finding date
2014-07-16
Cause of death
multidrug overdose including tramadol and methadone
AI-generated summary
Shannon Lees, a 23-year-old with schizoaffective disorder and polysubstance abuse, absconded from a mental health rehabilitation unit and died from multidrug overdose involving tramadol and methadone (not prescribed to him). The methadone was likely diverted from a community acquaintance dispensed methadone for opioid replacement therapy. The coroner found that clinical care at the rehabilitation unit was appropriate. However, the inquest highlighted systemic failures in regulating takeaway methadone dosing in Victoria. Between 2010-2013, at least 58 confirmed deaths involved diverted takeaway methadone, with rates increasing significantly after 2006 when access to takeaway doses was liberalised. The coroner expressed concern that Victoria permits substantially more takeaway doses than other states, and that neither prescribers nor dispensers adequately verify safe storage and prevent diversion through objective evidence, relying instead on unreliable client self-report.
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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