157 results
44y · Female·Unascertained
A 44-year-old woman with chronic pain, epilepsy, and opioid dependence died at home with an unascertained cause in the setting of prescription medication use. She was a known 'doctor shopper' who obtained opioids from mu…
0y · Female·Morphine toxicity
Tamiya Calais Lievesley, a six-month-old infant, died from morphine toxicity on 2 March 2004. She ingested a fatal dose of morphine, likely administered by one of her parents who were both morphine-dependent. The coroner…
35y · Male·serotonin syndrome
Nicholas Moorby, a 35-year-old male, was found deceased at home in Lynbrook, Victoria on 11 April 2013, having last been seen alive on 9 April 2013. The coroner determined he died from serotonin syndrome. Moorby was pres…
29y · Male·Combined methadone, diazepam and clonazepam toxicity in a man commencing a metha…
Phillip Black, age 29, died from combined methadone, diazepam and clonazepam toxicity after commencing methadone maintenance therapy. He presented to Dr D. on 23 September 2010 seeking to re-commence MMT, having previous…
45y · Female·terminal epileptic seizure
Annalies Malm, a 45-year-old woman with cerebral palsy, severe intellectual disability, and epilepsy, died from a terminal epileptic seizure with aspiration pneumonia. She received incorrect medication on 7 May 2012 by a…
48y · Male·Haemophilus influenzae bronchopneumonia in the setting of alcohol and methadone …
Peter Oelfke, a 48-year-old man with alcohol and opioid dependence, died from haemophilus influenzae bronchopneumonia complicated by alcohol and methadone toxicity. He had no fixed address and lived in a tent. His GP pre…
86y · Male·Acute on chronic renal failure secondary to rhabdomyolysis as a consequence of d…
An 86-year-old man with chronic renal impairment (eGFR 37) died from acute-on-chronic renal failure secondary to rhabdomyolysis caused by a contraindicated drug interaction. His GP prescribed clarithromycin for a chest i…
22y · Male·mixed drug toxicity due to methadone, codeine, and morphine (metabolite), compou…
William Wallrock, 22, died from mixed drug toxicity four days after wisdom tooth extraction. He was initially appropriately advised to use paracetamol and ibuprofen. When inadequate pain relief prompted him to seek furth…
66y · Male·multiple organ failure associated with the combined effects of complications of …
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 wee…
42y · Male·Cardiac arrhythmia secondary to electrolyte imbalance (hyperkalaemia) and verapa…
Glen Kingsun, 42, died from cardiac arrhythmia secondary to electrolyte imbalance and verapamil toxicity. He had complex medical needs requiring multiple specialist and GP care. Critical failures occurred: (1) Medication…
Christopher Salib: ischaemic heart disease with multiple prescription drug toxic…
This landmark inquest examined three deaths involving prescription drug toxicity: Christopher Salib (24, ischaemic heart disease with drug toxicity), Nathan Attard (34, multi-drug toxicity), and Shamsad Akhtar (35, multi…
45y · Female·Pethidine toxicity
Maree Arthur died from pethidine toxicity at home on 2 February 2008, aged 45. She had complex chronic pain from previous surgeries and motor vehicle injury. Her GP, Dr Phillips, prescribed large quantities of pethidine …
70y · Female·Aspiration pneumonia, associated with Huntington's disease
Beryl Watson, a severely disabled 70-year-old with advanced Huntington's disease and dementia, died of aspiration pneumonia following a three-week respite stay at a BUPA aged care facility. Critical failures included: om…
92y · Female·Ischaemic heart disease in the setting of inappropriate administration of antihy…
Norma Bensley, a 92-year-old aged care resident, died from ischaemic heart disease after being inadvertently administered another resident's antihypertensive medications. A newly qualified nurse administered the wrong me…
84y · Female·Major cerebral infarct due to hypoglycaemia
Marie Goder, an 84-year-old with diabetes, developed severe hypoglycaemia following insulin administration at a nursing home on 1 November 2009, resulting in prolonged unconsciousness and bilateral cerebral infarcts. Aft…
76y · Female·colchicine toxicity
A 76-year-old woman with gout died from colchicine toxicity after being prescribed 500µg three times daily on 9 December 2010 for an acute attack. She developed diarrhoea from 15 December and died on 19 December with a p…
32y · Male·Multiple drug toxicity (including heroin)
Kirk Steven Ardern, a 32-year-old male with a long history of opioid dependence and substance abuse, died from multiple drug toxicity (including heroin) three days after release from prison. Two critical clinical failure…
33y · Male·toxic effects of oxycodone
A 33-year-old man died from oxycodone toxicity after his general practitioner prescribed escalating doses of the opioid for intermittent migraines over 14 months (5-30mg daily), despite a prior rejection of a pethidine a…
67y · Female·Lithium toxicity with chest infection and bipolar disorder; Alzheimer's disease …
Mrs Snopek, aged 67 with bipolar disorder on long-term lithium, was prescribed coversyl (an ACE inhibitor) by Dr A. in January 2008 for hypertension. This combination is contraindicated as ACE inhibitors impair renal fun…
87y · Female·heart failure and probable pneumonia in an elderly lady complicated by morphine …
An 87-year-old woman with dementia, heart disease, and hypertension presented with chest pain and hypoxia. A locum doctor (Dr B.) administered 20mg morphine intramuscularly without reviewing the patient's notes, medical …
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