Male child aged 20 months - Non-inquest findings

20y · Male·Lung infection on a background of oxycodone intoxication

A 20-month-old Aboriginal boy died from lung infection on a background of oxycodone intoxication after ingesting oxycodone tablets located in his grandparents' home. The child's grandparents had obtained 560 oxycodone tablets in the month preceding his death from Dr S., who prescribed excessive doses without appropriate safeguards. The grandfather was prescribed average daily doses of 800mg OxyContin despite best practice thresholds of 120-200mg. Dr S. failed to seek required approvals before prescribing controlled drugs to patients at risk of drug dependence, demonstrating substantial lack of judgement. The coroner found insufficient evidence to determine exactly how the child ingested the drug but emphasised the critical importance of real-time prescription monitoring systems, practitioner vigilance regarding drug-seeking behaviour, and proper assessment of drug dependence before prescribing Schedule 8 substances.