Coronial
VIChome

Finding into death of Phillip James King

Deceased

Phillip James King

Demographics

52y, male

Coroner

Coroner Audrey Jamieson

Date of death

2017-12-22

Finding date

2019-10-07

Cause of death

Mixed drug toxicity

AI-generated summary

A 52-year-old man with multiple sclerosis, chronic pain, depression and history of suicidality died from mixed drug toxicity following an intentional overdose. He was prescribed multiple opioids (fentanyl, tramadol, oxycodone), benzodiazepines, pregabalin and sertraline by multiple prescribers without coordinated oversight. PBS records revealed he obtained significantly more pregabalin and diazepam than therapeutically indicated, and received two fentanyl prescriptions only 6 days apart. Clinical lessons include: implementing real-time prescription monitoring for all drugs including pregabalin; coordinating prescribing across multiple clinicians; recognising medication misuse in patients with legitimate chronic pain; and recognising overdose signs (abnormal breathing, unarousable sleep) in witnessed cases to enable intervention.

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

Specialties

general practiceneurologypain medicinepsychiatryforensic medicine

Error types

medicationcommunicationsystem

Drugs involved

fentanyltramadoldiazepampregabalinsertralineoxycodoneparacetamolmeloxicamduloxetine

Clinical conditions

multiple sclerosischronic neuropathic painchronic depressionanxietychronic obstructive airway diseasesuicidalitymedication dependenceopioid misuse

Contributing factors

  • Intentional overdose with prescribed medications
  • Uncoordinated prescribing by multiple clinicians
  • Absence of real-time prescription monitoring for pregabalin and sertraline
  • Chronic depression and suicidality
  • Chronic pain with inadequate non-pharmacological management
  • Financial strain and inability to maintain work capacity
  • Patient medication misuse and self-escalation of doses
  • Lack of integrated care coordination between GPs and specialists

Coroner's recommendations

  1. Department of Health and Human Services review the rationale for excluding pregabalin from the Real Time Prescription Monitoring scheme
  2. Department of Health and Human Services consult with the Royal Australian College of General Practitioners and other relevant bodies to consider how targeted education on overdose risk, overdose recognition and response can be provided to families and partners of people prescribed strong opioids
Full text
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Source and disclaimer

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