Finding into death of Robert Anderson

50y · Male·Complications of right buttock necrotising fasciitis secondary to chronic right buttock intramuscular injections

50-year-old male with chronic pain from jockey injuries became dependent on morphine. General practitioner prescribed intramuscular (IM) morphine for self-administration at home from 2005–2007 at doses of 120–240mg daily without appropriate permits, specialist input, or clear treatment plan. Repeated IM injections to the buttock caused necrotising fasciitis, leading to sepsis, multi-organ failure, and death. The coroner found Dr O'Toole's practice of prescribing high-dose IM morphine for home self-injection to a patient with prior drug dependence fell far below accepted standards. No medical expert supported this approach. Proper chronic pain management should have involved oral sustained-release formulations, specialist consultation, structured treatment protocols, and monitoring. The permit system also failed oversight functions.