Finding into death of Tate Hobbs
Deceased
Tate Ashley Hobbs
Demographics
36y, male
Coroner
Coroner Darren Bracken
Date of death
2019-02-06
Finding date
2021
Cause of death
Combined drug toxicity (pregabalin, morphine, amitriptyline)
AI-generated summary
A 36-year-old motor mechanic with chronic pain from a 2014 knee injury died from combined drug toxicity (pregabalin, morphine, amitriptyline). His general practitioner, Dr Schneider, prescribed excessive amounts of multiple medications significantly exceeding clinical directions—pregabalin at 1430mg daily (three times directed dose), oxycodone at 103mg daily (exceeding directions), amitriptyline at 173mg daily (double directed dose), and codeine concurrently. Despite notification in October 2018 of possible prescription shopping, Dr Schneider took no action. He failed to obtain required permits for Schedule 8 opioids, ignored recommendations from pain management specialists to reduce opioids, and maintained poor clinical documentation. The concurrent prescription of multiple central nervous system depressants created substantial overdose risk. Dr Schneider's prescribing was unsafe due to inadequate monitoring, coordination failure with specialists, and failure to address warning signs of medication dependence and diversion.
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
Contributing factors
- Prescription of pregabalin in doses significantly exceeding clinical directions
- Prescription of oxycodone in doses exceeding clinical directions and therapeutic need
- Concurrent prescription of multiple opioids (oxycodone and codeine)
- Concurrent prescription of multiple central nervous system depressants
- Prescription of codeine for chronic pain despite no evidence base
- Failure to obtain required permits for Schedule 8 opioid prescribing
- Failure to respond to Medicare Prescription Shopping Programme notification
- Failure to coordinate with pain management specialists
- Failure to implement specialist recommendations for opioid weaning
- Obtainment of diverted liquid morphine from unknown source
- Inadequate medication review and monitoring
- Poor clinical documentation and record-keeping
- Failure to recognize signs of medication dependence
- Failure to investigate prescription shopping behavior
Coroner's recommendations
- The Victorian Department of Health should consider inclusion of pregabalin in the SafeScript real-time prescription monitoring scheme to reduce risk of harm associated with pregabalin
- AHPRA should consider these findings in relation to Dr Schneider's prescribing practices and take appropriate action to assist him in improving prescribing practices and understanding the significance of obtaining relevant permits to prescribe opioid medications
Full text
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