Finding into death of Daniel Isaac Semple

Contributing factors

• Unsupervised takeaway methadone dosing prescribed despite evidence of injecting methadone
• Reliance on patient self-reports rather than objective evidence to assess suitability for takeaway dosing
• Failure to perform required urine drug screening during treatment
• Non-compliance with urine toxicology policy
• Continuation of takeaway doses despite documented heroin use
• Long-term benzodiazepine prescribing without tapering plan implementation
• Failure to detect methadone injection misuse
• Lack of independent verification of patient stability claims
• High cumulative dose of central nervous system depressants
• Inadequate documentation of clinical decision-making and safety discussions

Coroner's recommendations

1. Implementation and compliance with the 2016 Policy for Maintenance Pharmacotherapy for Opioid Dependence, particularly the revised Checklist for assessing appropriateness of takeaway doses
2. Mandatory use of SafeScript when prescribing methadone to review patient prescription history of Schedule 8 and high-risk medicines
3. Regular urine drug screening in accordance with policy (every one to two visits)
4. Objective assessment of patient stability using multiple sources of information rather than reliance on patient self-reports alone
5. Documentation of clinical reasoning for takeaway dosing decisions using the structured Checklist approach
6. Liaison with dosing pharmacists to corroborate clinical observations and patient presentation
7. Implementation of benzodiazepine tapering plans where documented
8. Consideration of absolute and relative contraindications to takeaway dosing, including evidence of drug misuse
9. Assessment of 'reasonable need' for takeaway doses before authorization
10. Regular reassessment of patients across all domains of the stability checklist