Coronial

60 results for medication seeking behaviour

TAShome2022-09-20

Coroner's Finding: Hill, Sandra Germaine

67y · Female·mixed prescription drug toxicity (oxycodone and oxazepam); central nervous syste…

… left, 'DNR' written on chest, farewell text message). Her prescriber appropriately assessed her for drug-seeking behaviour on each occasion oxycodone was prescribed and found no concerns. The coroner found no clinical …

general practiceoncologyoxycodone
VIChome2017-08-16

Finding into death of CPLH

32y · Male·Multidrug overdose

…epam, methadone, and other drugs from multiple prescribers and pharmacies. While some GPs recognised drug-seeking behaviour and ceased prescribing, others (notably Dr S.) continued providing high-risk prescriptions as r…

general practiceemergency medicinesystemcommunicationfentanyl
NSWmental health2014-05-08

Inquest into the death of Hugh David LISLE

24y · Male·cardio-respiratory arrest due to multi-drug toxicity

…eutic dosing; ensuring robust communication systems for clinically significant observations (patient drug-seeking behaviour); strict medication administration oversight; and maintaining advanced life support training fo…

psychiatryemergency medicinecommunicationsystemdiazepam
VIC2019-10-18

Finding into death of Mr A

24y · Male·Mixed drug toxicity

…el. He had a history of anxiety and shoulder pain following 2015 surgery, for which he received multiple medications including pregabalin, benzodiazepines, opioids, and stimulants from different prescribers. His girlfrie…

psychiatrygeneral practicecommunicationsystempregabalin
NThome2007-11-13

Inquest into the death of Richard Kiel

37y · Male·acute heart failure caused by multiple drug toxicity (methadone and alprazolam)

…levels of methadone and alprazolam, likely consumed on 9 September 2005. His GP, Dr G., prescribed these medications (including benzodiazepines contraindicated with methadone) from March 2001 onwards despite knowing Kiel…

general practiceaddiction medicinediagnosticmedicationmethadone
WAhome2016-02-10

Inquest into the Death of Adrian Marcus WESTLUND

22y · Male·Combined drug toxicity (alprazolam, methadone, diazepam, dextromethorphan and op…

Adrian Westlund, a 22-year-old with complex drug-seeking behaviour and polypharmacy addiction, died of combined drug toxicity (alprazolam, methadone, diazepam, de…

general practiceaddiction medicinediagnosticcommunicationalprazolam
SA2003-03-28

Coroner's Finding: ROGERS Justin Malcolm

27y · Male·propoxyphene toxicity

A 27-year-old man with schizophrenia died of propoxyphene toxicity while in police custody. He ingested a fatal dose of Doloxene capsules prescribed by Dr R. on 27 June 2000. The doctor prescribed 100 capsules to a patie…

general practicepsychiatrydiagnosticmedicationpropoxyphene
QLDhome2019-07-15

Male child aged 20 months - Non-inquest findings

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

…e 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.

general practiceforensic medicinediagnosticmedicationoxycodone
TAShome2026-01-07

Coroner's Finding: de-identified UN

43y · Male·hypoxic brain injury caused by cardiac arrest due to unintentional drug poisonin…

…been prescribed large quantities of pregabalin, temazepam, and tramadol by his GP despite documented drug-seeking behaviour and illicit substance use. While hospitalised for injection drug complications, he received unn…

general practiceemergency medicinemedicationdiagnosticmethadone
QLDhome2018-05-21

House, William John; White, Vanessa Joan; Smith, Jodie Anne and Milne, Daniel Keith

Unknown·acute fentanyl toxicity; acute oxycodone toxicity; multiple drug toxicity; opioi…

Four adults died from opioid overdoses (fentanyl and oxycodone) in Queensland between 2012–2014. All obtained prescriptions from multiple doctors ('doctor shopping') without effective detection. Systemic failures include…

general practicepain medicinediagnosticmedicationfentanyl
VIChome2014-02-13

Finding into death of Daniel Malcolm John Anderson

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…

general practicepsychiatrydiagnosticmedicationoxycodone
VIChospital2017-12-11

Finding into death of Karen Ann Moore

49y · Female·Bronchopneumonia, hypoxic brain injury, and combined drug toxicity (oxycodone an…

…uscitation. Over 15 months prior to death, she had seven hospital admissions for overdoses of prescribed medications. Her GP, Dr N., prescribed high-dose oxycontin (240mg/day) and diazepam despite repeated overdoses and …

general practiceemergency medicinemedicationcommunicationoxycodone
ACThospital2019-06-25

Inquest into the death of Jay Alan Paterson

43y · Male·hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic …

…odone tablets in August 2017 by leveraging regulatory differences between ACT and NSW, falsely reporting medications stolen or confiscated. On 30 August, Dr R. prescribed additional opioids after a phone call from Mr Pat…

general practicepain medicinesystemproceduraloxycodone
NSWhome2019-02-15

Inquest into the death of Margaret Rose CARR

62y · Female·Unknown. Likely natural causes, possibly with drug-related element. QT-prolongat…

…vulnerable patients with multiple comorbidities; ensuring adequate follow-up when prescribed psychiatric medications; recognising signs of serious illness in patients with hoarding and poor living conditions; coordinatio…

general practiceforensic medicineamitriptyline
NSWhome2018-07-27

Inquest into the death of Alissa Campbell

26y · Female·Multiple drug toxicity

Alissa Campbell, aged 26, died from accidental drug overdose caused by multiple prescription medications—predominantly codeine and doxepin in combination with benzodiazepines. She had accessed prescription dr…

general practiceaddiction medicinediagnosticmedicationcodeine
VIChome2016-04-04

Finding into death of Frank Edward Frood

47y · Male·Bronchopneumonia on a background of methadone and benzodiazepine use

… addiction') was dispensed excessively while clinical notes documented benzodiazepine dependence and drug-seeking behaviour; (3) Benzodiazepines potentiate methadone's respiratory depression; (4) Extensive 'prescription…

general practiceaddiction medicinemedicationsystemmethadone
VIChome2026-02-17

Finding into death of Laurence Mark O'brien

22y · Male·Mixed drug toxicity (tapentadol, clonazepam, citalopram, amphetamine, olanzapine…

…d to check SafeScript (Victoria's real-time prescription monitoring system) before prescribing monitored medications, perpetuating his addiction cycle. His regular treating team appropriately coordinated care with Webste…

general practicepsychiatrymedicationsystemtapentadol
WAmental health2001-02-02

Inquest into the Death of Giovanni Mario Franco

30y · Male·Acute Cardiac Dysrhythmia of Uncertain Aetiology

…iac dysrhythmia of uncertain aetiology. During his final admission in February 1998, he developed severe behavioural disturbance resistant to anti-psychotic medication, progressing to medication-induced delirium. He was…

psychiatryintensive caremedicationflupenthixol decanoate
QLDhospital2018-07-30

Matthew Douglas McLachlan - Non-inquest findings

28y · Male·Mixed drug toxicity (synergistic effects of diazepam, oxycodone, and fentanyl ca…

…GP on 6 June 2017, obtaining additional diazepam and oxycodone prescriptions. He self-administered these medications alongside hospital medications, achieving toxic levels. Critical lessons: clinicians should routinely a…

infectious diseasesemergency medicinecommunicationsystemfentanyl
VICcommunity2025-04-16

Finding into death of Jamie Peter Nisbet

47y · Male·Compression of the neck arising from hanging

… by psychiatry registrar Dr D. on 19 September, she concluded his presentation was non-genuine and he was seeking admission to avoid court. He was not admitted. Following a failed telehealth appointment on 20 September …

psychiatryemergency medicinecommunicationsystemrisperidone

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