Finding into death of KD
Deceased
KD
Demographics
56y, male
Date of death
2014-05-16
Finding date
2017-02-22
Cause of death
Aspiration of gastric content secondary to combined drug toxicity
AI-generated summary
A 56-year-old de-registered doctor died from aspiration of gastric content secondary to combined drug toxicity. He had a long history of prescription drug dependency and multiple mental health issues. Two general practitioners prescribed long-term benzodiazepines (diazepam, temazepam) and quetiapine over years without adequate oversight or specialist coordination. One GP mistakenly believed ongoing psychiatric supervision was occurring when contact had ceased in 2011. The other GP knew psychiatric care had ended but continued prescribing without intervention. Excessive quetiapine prescriptions resulted from default software settings generating unintended repeats. The deceased also accessed over-the-counter codeine-containing medications. Clinical lessons include: maintaining active communication between GPs and specialists about medication regimes, not assuming colleagues are reliable historians, implementing safeguards for high-risk patients with addiction histories, and monitoring non-scheduled drugs like quetiapine that are misused in addiction populations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Long-term prescribing of benzodiazepines without adequate oversight
- Excessive quetiapine prescribing due to software default settings generating unintended repeats
- Lack of communication between general practitioners and specialist
- Assumption that psychiatric oversight was ongoing when contact had ceased in 2011
- General practitioner treating a medical colleague with substance dependence history without appropriate safeguards
- Access to over-the-counter codeine-containing medications
- History of prescription drug dependency and opioid addiction
- Failure to report to Drugs and Poisons Regulation
- Depression and anxiety exacerbated by recent distressing family disclosure
Coroner's recommendations
- The Royal Australian College of General Practitioners consider the need for further education of its members in relation to the potential for misuse of quetiapine given the circumstances of this death
- The Royal Australian College of General Practitioners consider the circumstances of this death in the context of its existing guidelines on coordinating care between general practitioners and specialists, and determine whether more practical guidance is required for general practitioners in areas such as: (a) How long a general practitioner should rely on specialist prescribing advice before seeking updated advice; (b) How often a general practitioner should be in contact with a specialist if the general practitioner is relying on that specialist's advice to inform ongoing care
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