Finding into death of SO

27y · Male·Mixed drug toxicity

A 27-year-old man with polysubstance abuse disorder, generalised anxiety disorder, and borderline personality disorder died from mixed drug toxicity (heroin, morphine, diazepam, citalopram, quetiapine) shortly after discharge from The Geelong Clinic. Despite recent hospitalization for detoxification and evidence of ongoing substance use (positive amphetamine screens, discovery of syringes and powder in room), he was discharged with a follow-up appointment scheduled 8 days later. He travelled to Abbotsford after discharge and used heroin, collapsing and dying in an alley. Clinicians should recognize that brief periods of apparent improvement in mood and engagement during substance use disorder treatment do not eliminate imminent overdose risk, particularly following discovery of active drug use. Enhanced discharge planning, closer follow-up intervals, and consideration of extended inpatient care or supervised transition to rehabilitation facilities might have prevented this death.