Finding into death of John Raymond Gilbett
Deceased
John Raymond Gilbett
Demographics
54y, male
Date of death
2011-09-11
Finding date
2014-12-12
Cause of death
hanging
AI-generated summary
John Raymond Gilbett, aged 54, died by hanging on 11 September 2011. He had chronic pain and opioid dependence managed by general practitioners, and chronic mental illness from a 2001 motor vehicle accident. His GP prescribed varenicline (Champix) for smoking cessation in February 2011; he self-recommenced in late August. His ex-wife reported dramatic mood changes and agitation coinciding with restart, describing him as fearful and feeling like he did after his accident. Clinical lessons: The coroner found no documented counselling or warning about psychiatric adverse effects when he reported self-recommencement, and no clinical review occurred. Current prescribing guidelines recommend concurrent counselling, clinical review within 2–3 weeks, warnings about psychiatric effects, and caution with serious psychiatric illness. While no definitive causal link was established, substantial post-market surveillance data document psychiatric adverse effects.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Clinical conditions
Contributing factors
- chronic opioid dependence
- chronic pain not relieved by drug therapy
- chronic mental illness from motor vehicle accident head injury
- separation from wife
- possible psychiatric adverse effects from varenicline
Coroner's recommendations
- Findings referred to Therapeutic Goods Administration for consideration of whether death constitutes a suspected adverse reaction to varenicline
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