Deceased
Mr A
Demographics
24y, male
Date of death
2016
Finding date
2019-10-18
Cause of death
Mixed drug toxicity
AI-generated summary
A 24-year-old man died from mixed drug toxicity after staying overnight at a backpackers hostel. He had a history of anxiety and shoulder pain following 2015 surgery, for which he received multiple medications including pregabalin, benzodiazepines, opioids, and stimulants from different prescribers. His girlfriend observed he was taking higher doses than prescribed. The toxicology showed therapeutic levels of multiple CNS depressants (pregabalin, clonazepam, buprenorphine, pholcodine) plus dexamphetamine and bupropion. He was found unresponsive with blue lips and unable to be resuscitated. Key clinical lessons: uncoordinated prescribing across multiple doctors allowed excessive pregabalin accumulation without awareness of drug interactions; no clinician had an overview of his complete medication regimen; CNS depressant combinations (pregabalin with benzodiazepines and opioids) create fatal respiratory depression risk. The implementation of SafeScript prescription monitoring and inclusion of pregabalin would likely have prevented this death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (s…
Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons includ…
36y · Male·Drowning
Gary Dale Sargeant, a 36-year-old Royal Australian Air Force member, died by drowning after absconding from Edinburgh Health Centre during an acute mental health crisis. Critical clinical failures included: a clinical ps…
59y · Male·Multiple injuries
Martin Carl Quiterio, a 59-year-old man with longstanding schizophrenia and suspected autism spectrum disorder, died on 3 January 2024 when he jumped from the 14th floor of a car park in West Perth. He had been discharge…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —