99 results for “medication misuse”
56y · Male·Hanging
A 56-year-old man with a long history of bipolar affective disorder and alcohol misuse died by hanging between 18–20 December 2018. He presented to hospital on 16 December after expressing suic…
33y · Male·ketoacidosis, likely alcoholic ketoacidosis
…ity in Hobart. He had a long history of schizophrenia, involuntary mental health admissions, and substance misuse. In the weeks before death, he exhibited concerning behaviours including drug manufacturing, disordered co…
56y · Male·Aspiration of gastric content secondary to combined drug toxicity
…e settings generating unintended repeats. The deceased also accessed over-the-counter codeine-containing medications. Clinical lessons include: maintaining active communication between GPs and specialists about medicatio…
58y · Female·undetermined; possible mixed drug intoxication and/or adrenal insufficiency
…dditional CNS depressants (citalopram, nitrazepam) not prescribed to her, which when combined with other medications increased overdose and serotonin toxicity risk. The coroner found the prescribing regime itself appropr…
25y · Male·hanging
A 25-year-old university student with a complex history of schizoaffective disorder and substance misuse died by hanging during family leave from a mental health ward. He had been stable on depot antipsychotic m…
17y · Male·Unascertained in the setting of volatile substance abuse
…ccommodated; (5) awareness of chroming among some staff was not documented or escalated; and (6) substance misuse was not referred for specialist intervention despite clear indicators. Better integration between agencies…
30y · Male·Mixed drug toxicity (methadone, amitriptyline, alprazolam, diazepam, oxazepam, n…
Benjamin Appelman, 30, died from mixed drug toxicity in a creek in December 2010. He had engaged in prescription shopping across multiple GPs and pharmacies to obtain benzodiazepines, obtaining 1050 alprazolam, 1540 diaz…
Christopher Salib: ischaemic heart disease with multiple prescription drug toxic…
…ti-drug toxicity). All died from lethal combinations of benzodiazepines, opioids, and other prescription medications obtained through multiple doctors ('doctor shopping'). Key failures included: lack of real-time prescri…
37y · Male·mixed drug toxicity
… mixed drug toxicity. Over four months, he obtained prescriptions from 19 different doctors for multiple medications including opioids and benzodiazepines. His brother observed signs of intoxication and removed accessibl…
51y · Female·Cannot be determined; likely mixed drug (including alcohol) toxicity or undeterm…
… polypharmacy regimens; (3) accessing real-time prescription monitoring systems (DORA) to detect potential misuse; (4) ensuring current regulatory authorities are maintained when prescribing Schedule 8 substances; and (5…
25y · Male·Combined drug toxicity
…sufficient evidence that clinical care directly caused the death, as Mr Ladd was also using unprescribed medications (codeine, diazepam, pholcodine) from unclear sources. Key lessons: SafeScript must be checked every tim…
32y · Male·Mixed drug toxicity (codeine, methadone, alprazolam, diazepam) in a man with cor…
James Dougan, 32-year-old man with longstanding polysubstance abuse, died from mixed drug toxicity (codeine, methadone, alprazolam, diazepam) complicated by severe coronary artery atherosclerosis. He engaged in prescript…
53y · Male·Gunshot wound to the head
RC, a 53-year-old man with longstanding depression, died by suicide on 15 April 2014. He was under care of Campbelltown Community Mental Health (CoMHET) when a critical clinical failure occurred: a handwritten progress n…
29y · Male
Anthony Fahey, aged 29, was last seen on 3 July 2013 in Canberra after purchasing a bus ticket to Sydney. He was grappling with personal issues including alcohol use, mental health concerns, and existential questions abo…
48y · Male·combined drug intoxication from morphine and quetiapine
…regularly under false pretenses. Dr H. was unaware of Cashion's Tasmanian treatment, his history of opioid misuse and doctor-shopping, or the contraindication of combining morphine with Subutex. The coroner found Dr H. s…
43y · Male·hypoxic brain injury caused by cardiac arrest due to unintentional drug poisonin…
…d at different pharmacies. He then injected his partner's methadone in combination with these prescribed medications and other drugs, causing fatal cardiorespiratory depression. The coroner found the prescribing pattern …
34y · Female·Combined drug toxicity (gabapentin, oxycodone, tramadol, diazepam, citalopram, d…
…ribers and dispensers despite 66 system notifications in the year before death; incomplete disclosure of medications by the patient to clinicians; lack of real-time monitoring of gabapentin (not yet on SafeScript); and u…
44y · Female·Intoxication by the combined effects of tramadol, methadone, diazepam, codeine, …
Anne Christine Brain, a 44-year-old woman with schizophrenia, anxiety, and depression who was opioid-dependent, died from intoxication by combined effects of tramadol, methadone, diazepam, codeine, alprazolam, risperidon…
44y · Male·Unascertained; presumed exposure
…g, Western Australia on 28 January 2018. He had been drinking alcohol and was not carrying his essential medications (warfarin and levetiracetam). Medical staff had advised he was at high risk of seizures and stroke with…
40y · Male·Toxic effects of a gas
…where he witnessed a sexual assault. Despite treatment with a psychiatrist (Dr M.) and psychologist, and medication (Escitalopram, Imovane), his mental health deteriorated. Key clinical lessons include: the importance of…
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