Finding into death of Brenton James Grosser
Deceased
Brenton James Grosser
Demographics
49y, male
Date of death
2013-02-21
Finding date
2015-07-20
Cause of death
Drug toxicity (methadone)
AI-generated summary
Brenton Grosser, a 49-year-old man with alcohol addiction history, died from methadone toxicity after consuming three 100ml takeaway methadone bottles prescribed to his housemate. He had consumed significant alcohol (approximately 2 litres wine and 6 beers) the evening prior. The methadone bottles were left accessible in his housemate's room. Blood methadone concentration was 0.3 mg/L (within fatal range of 0.06-3.0 mg/L), with concurrent ethanol present. The coroner found methadone toxicity was the cause, likely accidental rather than intentional. This case highlights critical public health concerns regarding diversion of takeaway methadone doses and inadequate regulation of access. The coroner supported previous recommendations to restrict takeaway methadone to maximum two doses weekly with no consecutive doses, given at least 58 confirmed deaths from diverted methadone between 2010-2013 in Victoria.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Consumption of three 100ml takeaway methadone bottles prescribed to housemate
- Concurrent alcohol consumption (approximately 2 litres wine and 6 beers)
- Accessible storage of methadone in shared bedroom
- Additive CNS depressive effects of methadone and alcohol
- Lack of opiate tolerance increasing methadone toxicity risk
- Inadequate regulation of methadone takeaway dosing
Coroner's recommendations
- Victorian Department of Health request Advisory Group for Drugs of Dependence review circumstances of death when considering whether current takeaway dosing advice adequately balances client benefits with risks to public health and safety
- Victorian Department of Health request Advisory Group for Drugs of Dependence consider revising Policy for Maintenance Pharmacotherapy for Opioid Dependence to limit opioid replacement therapy clients to at most two takeaway methadone doses per week with no consecutive takeaway doses
- Advisory Group for Drugs of Dependence ideally report publicly on conclusions regarding access to takeaway methadone to inform Victorian public of rationale for stance on access
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