Finding into death of David John Main
Deceased
David John Main
Demographics
54y, male
Date of death
2019-10-14
Finding date
2021-08-16
Cause of death
Toxic leukoencephalopathy (of uncertain aetiology)
AI-generated summary
David Main, 54, died from toxic leukoencephalopathy of uncertain aetiology following a ketamine-assisted oxycodone detoxification at Beleura Private Hospital. He had chronic pain from multiple injuries and opioid dependence (330mg morphine equivalents daily). Dr T. initiated a seven-day ketamine infusion protocol with supportive medications. David became unexpectedly drowsy and developed fluctuating consciousness on day 6, with GCS dropping to 5/15. He was transferred to ICU with diffuse white matter disease on imaging. Despite investigation, the underlying cause of leukoencephalopathy could not be identified; ketamine has not been reported to cause this condition. The CPU review found Dr T.'s management and hospital care reasonable with no identifiable prevention opportunities. The case highlights the rarity and unpredictability of toxic encephalopathy in this clinical context.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Clinical conditions
Contributing factors
- Ketamine infusion for pain management
- Opioid reduction protocol
- Multiple medications used concurrently (quetiapine, clonidine, diazepam, zopiclone, ondansetron)
- Unexplained increased sensitivity to opioids
- Fluctuating level of consciousness during treatment
- Possible unidentified toxin or drug interaction
Coroner's recommendations
- Copy of finding provided to AHPRA as per standard procedure in coronial investigation
Full text
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