Deceased
Jessica Higgins
Demographics
33y, female
Coroner
Coroner Simon McGregor
Date of death
2017-06-04
Finding date
2020-04-16
Cause of death
Hypoxic ischaemic encephalopathy complicating mixed drug toxicity
AI-generated summary
Jessica Higgins, a 33-year-old woman with chronic pain on high-dose opioids, underwent ketamine infusion with planned opioid rotation to methadone in May 2017. She was discharged on 23 May on methadone 5mg twice daily plus up to 15mg as-needed. On 26 May, after phone discussions with two treating doctors about inadequate pain control, her methadone was increased to 10mg three times daily without in-person review. She was found unresponsive on 27 May with severe hypoxia and died from hypoxic-ischaemic encephalopathy. Critical failures included: ambiguous communication between doctors via text message without documented clinical reasoning; failure to assess dangerous sedation her mother had observed; lack of structured post-discharge plan; and absence of in-person review before dose escalation. The coroner found both doctors' care below standard and referred them to AHPRA, emphasizing that poor communication rather than lack of knowledge led to this preventable death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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