Coronial
VIChospital

Finding into death of Nathan Dimech

Deceased

Nathan Dimech

Demographics

17y, male

Date of death

2013-11-01

Finding date

2016-08-31

Cause of death

Global cerebral ischaemic injury and aspiration pneumonia post cardiac arrest due to methadone toxicity

AI-generated summary

Nathan Dimech, a 17-year-old with intellectual disability and substance abuse issues, died from methadone toxicity after consuming his father's opioid replacement therapy (ORT) dose from a refrigerator. Nathan's father, a long-term methadone client, stored multiple take-away bottles unsecured at home despite policy requirements for safe storage away from children and other drug users. The treating GP knew Nathan was living with his father from September 2013 but did not communicate this change to the dispensing pharmacist or alter prescribing. While initial pharmacy consultation covered storage safety, follow-up conversations about home circumstances were unclear. Clinical lessons: ORT prescribers must actively communicate known changes in household composition (especially presence of vulnerable individuals) to dispensing pharmacists; pharmacists should have regular documented discussions about storage safety and household circumstances; and safe storage mechanisms (locked boxes) should be actively promoted and provided to reduce preventable deaths from methadone diversion to unintended users.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

general practicepharmacyemergency medicineintensive carepaediatricsaddiction medicine

Error types

communicationsystemdelay

Drugs involved

methadonediazepamsodium valproatelidocaine

Clinical conditions

methadone toxicityopioid dependencecardiac arrestglobal cerebral ischaemic injuryaspiration pneumoniaintellectual disabilityattention deficit disorderdepressionsubstance abuse disorder

Contributing factors

  • Unsafe storage of methadone in family refrigerator without secure locking mechanism
  • Failure of prescribing GP to notify dispensing pharmacist of change in household composition (17-year-old son now living with father)
  • Lack of documented follow-up discussions between pharmacist and patient regarding storage safety and household circumstances
  • Vulnerable adolescent with intellectual disability, substance abuse issues, and depression following grandfather's death
  • Father's substance abuse and encouragement of Nathan's drug use
  • Inadequate supervision and monitoring of take-away methadone dosing arrangements

Coroner's recommendations

  1. That the Department of Health and Human Services review the safe methadone storage section of its Policy for Maintenance Pharmacotherapy for Opioid Dependence, and consider whether any further action can be taken to encourage safe storage of methadone. In particular, DHHS could consider whether distributing lockable boxes to methadone clients might be effective, as an appropriate response to the death of Nathan Dimech and in the context of six deaths between 2010 and 2013 of young people under the age of eighteen years.
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