Inquest into the Death of Matthew Neil Hardy TONKIN
Deceased
Matthew Neil Hardy TONKIN
Demographics
24y, male
Coroner
Coroner King
Date of death
2014-07-03
Finding date
2019-05-10
Cause of death
bronchopneumonia complicating oxycodone toxicity
AI-generated summary
Matthew Neil Hardy Tonkin was a 24-year-old Australian Army veteran with post-traumatic stress disorder and chronic pain who died from bronchopneumonia complicating oxycodone toxicity. He engaged in prescription shopping across multiple doctors and pharmacies, obtaining oxycodone and benzodiazepines despite prior overdoses. A GP in Claremont prescribed controlled-release oxycodone (20mg and 80mg tablets) on 1 July 2014 without checking prescription history or drug addict registers, unaware he was a documented drug addict. His tolerance had decreased due to limited access in June, making him opioid-naïve when he fatally overdosed. Key clinical lessons: real-time prescription monitoring systems were unavailable; ADF medical records were difficult to access; discharge summaries indicating opioid dependence were altered or unavailable to treating doctors; GPs lacked awareness of the deadly combination of opioids with benzodiazepines; and chronic pain management over-relied on opioids rather than multidisciplinary approaches.
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Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- prescription shopping across multiple doctors
- lack of real-time prescription monitoring system
- inability to access ADF medical records
- falsified medical records provided to GPs
- decreased opioid tolerance due to reduced access in June 2014
- combination of oxycodone with benzodiazepines
- lack of awareness of drug-seeking behaviour
- prescription of high-dose controlled-release oxycodone to new patient without verification
- absence of coordination between Queensland and Western Australian healthcare systems
Coroner's recommendations
- Western Australian Department of Health to liaise with Department of Defence to implement a procedure for timely transfer of medical records of ADF members and veterans to treating medical professionals in Western Australia
Full text
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