Inquest into the Death of Daniel LAHENGKING

66y · Male·multiple organ failure associated with the combined effects of complications of methotrexate toxicity, vasculitis and atherosclerotic cardiovascular disease

Daniel Lahengking, a 66-year-old Indonesian visiting family in Esperance, was diagnosed with rheumatoid arthritis by locum GP Dr H. and prescribed methotrexate 5-10mg daily, a grossly excessive dose (normal: 7.5-20mg weekly). The pharmacist dispensed it without proper labelling after flagging concerns but failing to resolve them effectively. The patient developed severe toxicity with vomiting, diarrhoea and mouth ulcers. When he returned with symptoms, Dr H. misdiagnosed urinary tract infection and failed to investigate the methotrexate. He was later hospitalized with severe immunosuppression, triggering tuberculosis reactivation, gastrointestinal bleeding and sepsis. Although the immediate methotrexate toxicity resolved, subsequent complications including vasculitis and coronary artery disease led to his death. Clinical lessons include: always obtain baseline blood tests before methotrexate; consider medication toxicity in differential diagnosis; pharmacists must effectively escalate safety concerns about unusual prescriptions; and methotrexate carries serious toxicity risks requiring careful patient selection and monitoring.