Deceased
Darren James Fielding
Demographics
29y, male
Coroner
Coroner Leveasque Peterson
Date of death
2018-05-26
Finding date
2023-10-30
Cause of death
Methadone toxicity
AI-generated summary
Darren James Fielding died in custody at Middleton Prison on 26 May 2018 from methadone toxicity. He was on day 6 of opioid substitution therapy (OSTP) when he received his prescribed 10mg methadone dose. Expert evidence concluded he must have ingested more than 10mg to die from methadone toxicity. Critical deficiencies in Schedule 8 register documentation, recordkeeping practices, and failure to document a spill of another prisoner's dose prevented definitive determination of whether an incorrect higher dose was administered. The coroner found inadequate record-keeping in breach of policies and noted that while nursing staff maintained they gave the correct dose, poor documentation created an impediment to investigation. Key lessons: rigorous Schedule 8 compliance, contemporaneous accurate recording of all methadone doses and discrepancies, weight-checking of Imprest stock bottles, and clear handover procedures during prisoner transfers to ensure clinical reviews aren't missed.
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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