Finding into death of DA
Deceased
DA
Demographics
38y, male
Date of death
2019-03-11/2019-03-14
Finding date
2021-09-08
Cause of death
Mixed drug toxicity
AI-generated summary
DA was a 38-year-old man who died from mixed drug toxicity involving sedating medications and alcohol. He had longstanding severe anxiety and became dependent on codeine and benzodiazepines, initially obtained from multiple prescribers ('doctor shopping'). After disclosure of his dependence, GP Dr H. established a therapeutic relationship and supervised a gradual tapering plan with monitoring. DA complied reasonably well from January 2019 onward and had ceased additional doctor shopping. However, he was also obtaining quetiapine at approximately three times the prescribed dose from repeat scripts, was vulnerable to alcohol use, and combined multiple sedating medications with alcohol. The coroner found Dr H.'s care reasonable but noted opportunities to improve coordination across prescribers, better integrate mental health and addiction services, and enhance safety monitoring through SafeScript to prevent such iatrogenic addictions.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Longstanding severe anxiety disorder not adequately managed despite multiple interventions
- Opioid and benzodiazepine dependence developed through doctor shopping across multiple prescribers
- Excessive use of quetiapine at approximately three times prescribed dose despite only needing one tablet daily
- Combination of multiple sedating medications at high doses including codeine, diazepam, zolpidem, quetiapine and antidepressants
- Concurrent alcohol use with sedating medications
- Incomplete communication and coordination between prescribers due to patient compartmentalising care
- Lack of integrated dual diagnosis approach combining mental health and addiction services
- Mental health crisis including relationship breakdown and job loss in weeks prior to death
- Resistance to specialist addiction services referrals despite offers from treating psychiatrists
Coroner's recommendations
- Department of Health review and amend SafeScript training modules for health professionals to include advice about: exploring effects of other CNS-active medications not recorded in SafeScript (antidepressants, antipsychotics) that increase risk in combination; discussing with patients prescribed quetiapine the details of use, timing and risks when combined with other medicines; educating patients about potential for accidental overdose with dosing routines and combinations of high-risk medicines; and educating patients using multiple sedating medications about implications of alcohol use due to CNS depressive effects
- Department of Health review and amend SafeScript educational materials for patients and families to include information about potential for accidental overdose and implications of alcohol use when taking multiple sedating medications
Full text
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