Inquest into the Death of Daniel James HALL

26y · Male·Multiple drug toxicity and bronchopneumonia

Daniel James Hall, aged 26, died on 31 July 2010 from multiple drug toxicity and bronchopneumonia after consuming approximately 10-12 OxyContin tablets over 24 hours, vastly exceeding the prescribed dose of one tablet every 12 hours. He was a registered drug addict receiving buprenorphine from Dr W. while simultaneously obtaining OxyContin from ENT anaesthetist Dr R., who was unaware of his drug addict status and past opioid dependency. The deceased concealed his current registered drug addict status from Dr R., presenting only a history of past drug problems. Critical clinical lessons include: prescribers must obtain and verify drug addict registration status before dispensing high-dose opioids, particularly for day procedures; communication gaps between practices and specialists contributed significantly; the deceased received 20 tablets dispensed in one supply despite his known history; and real-time electronic monitoring of controlled drug dispensing was not available. Lack of access to contemporaneous drug dispensing records prevented Dr R. from making an informed clinical decision. A secure, real-time prescription monitoring system would have prevented this death.