SJM - Non-inquest findings

57y · Male·Mixed drug toxicity, predominantly propoxyphene (Doloxene)

A 57-year-old man died from mixed drug toxicity, predominantly propoxyphene (Doloxene), combined with benzodiazepines. His GP of 13 years prescribed Doloxene for 10 years despite documented alcohol abuse history, which was contraindicated. The GP also prescribed multiple central nervous system depressants (Temazepam, Alprazolam) concurrently, significantly increasing overdose risk. The GP prescribed large quantities (100 capsules at a time) without adequate monitoring, despite the patient exceeding recommended daily doses (8 tablets/day vs maximum 6). No alternative pain management strategies, specialist referrals, or genuine medication reduction plans were documented. Key clinical lessons: Doloxene should be avoided in patients with substance abuse history; concurrent CNS depressants require careful justification and monitoring; long-term benzodiazepines need regular review and specialist input; prescribing practices require documentation of clinical reasoning, baseline investigations (ECG, renal function), and regular reassessment.