Finding into death of Nathan Carl Skewes
Deceased
Nathan Carl Skewes
Demographics
31y, male
Date of death
2012-06-10
Cause of death
mixed drug toxicity
AI-generated summary
Nathan Carl Skewes, age 31, died on 10 June 2012 from mixed drug toxicity involving his deceased wife's powerful palliative medications (fentanyl, ketamine, hydromorphone, morphine, codeine, paracetamol, cannabinoids). His wife Belinda had died of cancer in June 2011, leaving her medications unsecured in their home. Nathan experimentally used these substances in the weeks before his death, with some family awareness. There is no evidence the overdose was deliberate. The coroner identified a critical public health gap: no legal authority has responsibility for retrieving Schedule 8 and Schedule 4 medications from homes after patient death. The recommendation was that the Victorian Department of Health establish systematic retrieval mechanisms in consultation with Victoria Police, Ambulance Victoria, and RACGP, particularly for Schedule 8 opioids, to reduce unauthorized access and harm from these dangerous medications.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Unsecured access to deceased spouse's Schedule 8 and Schedule 4 palliative medications
- No established legal authority or system for retrieval of dangerous medications after patient death
- Experimental use of opioids and other palliative care medications
- Medications left in home environment after patient's death
Coroner's recommendations
- The Victorian Department of Health should consult with relevant bodies whose members have contact with families of the deceased after a death (such as Victoria Police, Ambulance Victoria, and the Royal Australian College of General Practitioners) to identify appropriate opportunities to retrieve medications (particularly Schedule 8 opioids) that had been prescribed to the deceased, to reduce harms associated with other people accessing and using those medications
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