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VIChome2022-01-31

Finding into death of Leeanne Matheson

52y · Female·Mixed drug toxicity (methadone, pregabalin, valproic acid, benzodiazepines)

A 52-year-old woman with chronic pain, epilepsy, and opioid dependence died from mixed drug toxicity after prescribed methadone, pregabalin, valproic acid, and benzodiazepines. She was admitted to Box Hill Hospital on 12…

addiction medicinegeneral practicemedicationcommunicationmethadone
TAShome2021-12-21

Coroner's Finding: O'Donnell, Margaret Joy

51y · Female·Cannot be determined; likely mixed drug (including alcohol) toxicity or undeterm…

Margaret Joy O'Donnell, aged 51, died between 9-15 June 2018. The cause of death could not be determined due to decomposition, but toxicology revealed mixed drug toxicity including fatal levels of methadone and hydromorp…

general practicepsychiatrymedicationsystemoxycodone
TAShome2021-12-17

Coroner's Finding: Tilley, Jennifer May

58y · Female·undetermined; possible mixed drug intoxication and/or adrenal insufficiency

Jennifer May Tilley, aged 58, died on 8 January 2018 with an undetermined cause, though mixed drug intoxication and adrenal insufficiency were potential contributors. She had complex medical conditions requiring chronic …

general practicerheumatologysystemcommunicationpethidine
NSWhospital2021-12-02

Inquest into the death of Joshua Szczudlo

33y · Male·Fatal cardiac arrhythmia, secondary to acute kidney injury

Joshua Szczudlo, a 33-year-old man with morbid obesity (estimated weight 195kg), underwent shoulder fracture repair surgery on 17 March 2016 at Liverpool Hospital. He died 38 hours post-operatively from a fatal cardiac a…

orthopaedic surgeryanaesthesiasystemcommunicationmorphine
VIChospital2021-08-16

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 depende…

pain medicineanaesthesiaketamine
VIChospital2021-05-01

Finding into death of Sharni Dee Connolly

37y · Female·Multiple drug toxicity

Sharni Dee Connolly, a 37-year-old registered nurse turned naturopath, died from multiple drug toxicity following a hamstring injury requiring opioid analgesia. She was prescribed excessive quantities of pregabalin (105m…

general practiceemergency medicinemedicationcommunicationtapentadol
VIChospital2021-02-26

Finding into death of Ian Fraser

68y · Male·Complications of retroperitoneal haemorrhage due to inadvertent administration o…

Ian Fraser, 68, died from retroperitoneal haemorrhage following inadvertent dual anticoagulation with apixaban and enoxaparin. On 29 November 2019, a respiratory registrar attempted to prescribe discharge apixaban but mi…

respiratory medicinecardiothoracic surgerymedicationsystemapixaban
VIChome2021

Finding into death of Tate Hobbs

36y · Male·Combined drug toxicity (pregabalin, morphine, amitriptyline)

A 36-year-old motor mechanic with chronic pain from a 2014 knee injury died from combined drug toxicity (pregabalin, morphine, amitriptyline). His general practitioner, Dr Schneider, prescribed excessive amounts of multi…

general practicepain medicinemedicationcommunicationpregabalin
NSWhospital2020-11-20

Inquest into the death of Melissa Stokes

49y · Female·Fatal Cardiac Arrhythmia

Melissa Stokes, 49, died from a fatal cardiac arrhythmia one day after successful abdominal hysterectomy and sling surgery. The coroner found the cause was not opioid-induced respiratory depression despite post-operative…

anaesthesiagynaecologycommunicationdelaytramadol
TAShome2020-11-09

Coroner's Finding: Spencer, Melissa Mary

54y · Female·mixed drug toxicity

A 54-year-old nurse with chronic pain from a 1990 back injury died from mixed drug toxicity involving morphine, codeine, doxylamine and nitrazepam. She was prescribed multiple CNS depressants for years despite being desi…

general practicepain medicinemedicationsystemmorphine
WAcommunity2020-10-02

Inquest into the Suspected Death of Jorn Jesper JENSEN

68y · Male·unascertained

A 68-year-old man with multiple chronic medical conditions including peripheral neuropathy, chronic pain, atrial fibrillation, dysphagia, and depression disappeared on 25 June 2017. He left home, drove his car to Lanceli…

general practicecardiologybuprenorphine
TAShome2020-06-12

Coroner's Finding: Arnold, Derek William

51y · Male·acute methadone toxicity

A 51-year-old man died from acute methadone toxicity with a blood level of 2.5 mg/L (within fatal range). He was prescribed methadone tablets by his GP for chronic pain management since at least March 2014. Investigation…

general practicepain medicinemedicationsystemmethadone
TAShome2020-05-14

Coroner's Finding: Cashion, Brett Matthew

48y · Male·combined drug intoxication from morphine and quetiapine

Brett Cashion, a 48-year-old man with chronic pain and mental health issues, died from combined morphine and quetiapine intoxication after injecting prescription morphine. He was receiving daily Subutex in Tasmania from …

general practicepain medicinecommunicationsystemmorphine
VIChospital2020-04-16

Finding into death of Jessica Higgins

33y · Female·Hypoxic ischaemic encephalopathy complicating mixed drug toxicity

Jessica Higgins, a 33-year-old woman with chronic pain on high-dose opioids, underwent ketamine infusion with planned opioid rotation to methadone in May 2017. She was discharged on 23 May on methadone 5mg twice daily pl…

pain medicineemergency medicinecommunicationdiagnosticmethadone
ACThome2020-02-24

Inquest into the death of Joanne Lea LOVELOCK

53y · Female·Combined effects of alcohol, amitriptyline, and methadone

Joanne Lovelock, a 53-year-old woman with chronic pain, died from combined effects of alcohol, amitriptyline, and methadone on Christmas Day 2015. She had developed opioid dependence while receiving legitimate pain manag…

general practicepain medicinesystemcommunicationalcohol
ACThome2020-02-07

Inquest into death of RODNEY WAYNE RUDD

67y · Male·aspiration of gastric contents, due to morphine toxicity, in the context of bila…

A 67-year-old man with chronic pain, pancreatitis, osteoporosis and emphysema died from aspiration of gastric contents due to morphine toxicity. He had been prescribed opioid medications (MS-Contin and Ordine) by his GP …

general practicepain medicinemorphine
QLD2020-01-24

Willersdorf, Maria

87y · Female·Hypoxic-ischaemic encephalopathy secondary to cardiac arrest, with valvular hear…

An 87-year-old woman died following a CT-guided epidural injection at a private radiology clinic. Although she had undergone the procedure for spinal pain, the radiologist performed an epidural injection at the T12 level…

radiologypain medicinediagnosticproceduralbupivacaine
VIChome2019-10-07

Finding into death of Phillip James King

52y · Male·Mixed drug toxicity

A 52-year-old man with multiple sclerosis, chronic pain, depression and history of suicidality died from mixed drug toxicity following an intentional overdose. He was prescribed multiple opioids (fentanyl, tramadol, oxyc…

general practiceneurologymedicationcommunicationfentanyl
QLDcommunity2019-08-02

Ms D - Non-inquest findings

47y · Female·Overdose of hydromorphone

A 47-year-old woman died from an intentional overdose of prescribed hydromorphone while residing at a domestic violence refuge. She had a history of depression, previous suicide attempts, and was in crisis following sepa…

psychiatrygeneral practicediagnosticcommunicationhydromorphone
ACThospital2019-06-25

Inquest into the death of Jay Alan Paterson

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

Jay Alan Paterson, a 43-year-old man with chronic pain and opioid dependence, died from hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic upper airway injury. He obtained 296 oxycodone table…

general practicepain medicinesystemproceduraloxycodone

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