Finding into death of David John Main

54y · Male·Toxic leukoencephalopathy (of uncertain aetiology)

David Main, 54, died from toxic leukoencephalopathy of uncertain aetiology following a ketamine-assisted oxycodone detoxification at Beleura Private Hospital. He had chronic pain from multiple injuries and opioid dependence (330mg morphine equivalents daily). Dr T. initiated a seven-day ketamine infusion protocol with supportive medications. David became unexpectedly drowsy and developed fluctuating consciousness on day 6, with GCS dropping to 5/15. He was transferred to ICU with diffuse white matter disease on imaging. Despite investigation, the underlying cause of leukoencephalopathy could not be identified; ketamine has not been reported to cause this condition. The CPU review found Dr T.'s management and hospital care reasonable with no identifiable prevention opportunities. The case highlights the rarity and unpredictability of toxic encephalopathy in this clinical context.